Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 14, 2022, October 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had previously 
been in the hospital and should not have a copayment for this inpatient stay. 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 $310 
copayment per day for days 1-7 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for days 8-90 of each in-network inpatient hospital stay. 
 
The Plan contract says the inpatient hospital stay copayment applies to each stay. Due to meeting your out-of-
pocket maximum, you have been asked to pay $1,865.76, which is less than the standard $310 copayment per 
day for the inpatient hospital stay. This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from October 14, 2022, 
October 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Durolane injection. 
 
You asked the Plan to pre-approve a repeat Durolane injection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee had 
significant improvement in pain from prior injections. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat injection may be allowed when the 
indications continue to be met, significant improvement in pain and functional capacity from the prior series of 
injections is documented in the medical record, the last injection was give at least six months. 
 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 repeat Durolane injection. Our 
reviewer says that the request for a repeat Durolane injection is not medically necessary. Our physician 
reviewer found he documentation in the medical record does not support that the enrollee in this case got 
significant improvement in pain and functional capacity from the prior injections. Therefore, the reviewer 
found that the request for a repeat Durolane injection 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 a repeat Durolane injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat Durolane injection.
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 you cannot walk due to having a bad infection and 
will need extensive therapy because you have multiple sclerosis. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary, and your needs can be met in another setting.  
 
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 you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 10, 
2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee's health and life would 
have been significantly and directly threatened if care was provided in a less intensive setting. The Plan denied 
your request. The Plan says the information received does not support that criterion were met for an inpatient 
hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the documentation does not support why the admission was anticipated to 
last more than 2 midnights, and could have been addressed under observation status. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided on December 10, 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 the services are medically necessary due to your 
complex medical issues. The Plan denied your request. The Plan says ongoing skilled care can be provided in 
an alternative setting.  
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement. However, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. You 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block.  
You asked the Plan to pre-approve genicular nerve block. You say that a genicular nerve block followed by 
radiofrequency ablation is a potentially effective treatment. The Plan denied your request. The Plan says this is 
considered experimental/investigational. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 provided on January 1, 
2023. 
 
You asked the Plan to pay for procedure codes 75726 and 75774. The Plan denied your request. The Plan says 
procedure codes 75726 and 75774 are considered inclusive to procedure code 37244. 
 
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, we have confirmed that code 75726 and 75774 are column II codes to column I code 37244; 
however, 75726 and 75774 were billed with a modifier.  
 
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 75726 and 75774. Our reviewer says that 
the use of -59 modifier with procedure codes 75726 add 75774 is not supported. Our reviewer found that 
according to CPT rules, 37244 includes all radiological supervision, interpretation, and imaging guidance. The 
record does not support that these were separately identifiable procedures; therefore, they are included in 
procedure code 37244. 
 
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 75726 and 75774 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75726 and 75774 provided on January 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with multiple 
power options (K0842) with additional items and accessories (codes E0955, E2604, E1007, E1012, E2361, 
E1028, E2311, E2313, and E2377). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair with multiple power options with 
additional items and accessories. You say that the enrollee's original power chair was approved in 2021, but 
due to being struck by a motor vehicle while crossing a crosswalk, it has been damaged beyond repair. You 
also say that you are requesting a replacement power wheelchair for the enrollee. The Plan denied your request. 
The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for which a group 3 
power wheelchair is medically needed. The Plan also says there is no medical need for multiple power options 
included with a Group 3 power wheelchair K0861 base. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option power wheelchair 
(PWC) (K0841, K0842, K0843) is covered if certain criteria are met. Medicare rules also say if the PWC 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 a Group 2 standard power wheelchair 
with multiple power options with additional items and accessories. Our reviewer says that the enrollee does not 
meet the coverage criteria for a Group 2 standard power wheelchair. Our physician reviewer found the 
provided records from the prescribing physician do not support that the enrollee is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Physician's records do not document 
the enrollee performs bladder self-catheterization and is unable to transfer independently or that they have 
increased muscle tone or spasticity to meet criteria for the power tilt and/or recline and thus the multiple power 
option wheelchair base. Our reviewer found that the physician's records do not document the enrollee has a 
musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee, or 
the enrollee has significant edema of the lower extremities that requires a power elevating leg rest. Our 
physician reviewer also found that as the wheelchair base does not meet criteria for approval, the requested 
accessories are not covered. 
 
 
 
 
 
 
 
 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 standard power wheelchair with multiple power options with 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 2 standard power wheelchair with multiple power options (K0842) with additional items and 
accessories (codes E0955, E2604, E1007, E1012, E2361, E1028, E2311, E2313, and E2377).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that it is not safe for you to be at home by yourself 
because your body is still weak. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and your needs can be met at a lower level of care.  
 
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 that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuropsychological evaluation. 
 
You asked the Plan to pre-approve a neuropsychological evaluation. You say that you hoped that with in-office 
counseling, along with their review and evaluation of your current medications, there may be a better way to 
control your anger. The Plan denied your request. The Plan says there is no evidence of cognitive or behavioral 
impairments. The Plan also says there are no subjective complaints or objective evidence of memory loss. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is considered medically 
necessary for the indications listed in the Medicare rules section of this letter.  
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 neuropsychological evaluation. Our 
reviewer says that a neuropsychological evaluation is not medically reasonable and necessary. Our physician 
reviewer found you have had difficulty with anger issues which you are undergoing individualized counseling. 
The documentation shows you to be responding to individualized therapy as well as couples therapy. Our 
reviewer found that you do not meet the criteria as you are not showing severity of symptoms that would 
warrant this type of diagnostic. Therefore, this request does not appear medically necessary or reasonable. Our 
physician reviewer also found that the neuropsychological testing as outlined documentation is unclear in the 
reasoning for the testing to be obtained or what is to be achieved. 
 
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 neuropsychological evaluation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a neuropsychological evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on December 28, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was 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 the nursing facility care 
provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93923 billed for date of service December 29, 2022. 
 
You asked the Plan to pay for code 93923. You did not provide a specific argument with your appeal. The Plan 
denied your request. The Plan says code 92923 is not supported by the medical record. There is a more 
appropriate code that should have been billed. The Plan also says that code 93926-59 has been paid. 
 
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 93923 is Complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels. 
 
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 93923. Our reviewer says that code 93923 is not 
supported by the medical records. Our reviewer found the procedure report does not include sufficient documentation to confirm a complete bilateral noninvasive study was performed.  The procedure report 
describes studies completed on the right lower extremity.  There is a more appropriate code to report to support 
procedure documented.  
 
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 93923 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93923 billed for date of service December 29, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the enrollee has an 
active right sided foot wound with granulation tissue. Currently the enrollee is receiving a wound care protocol 
that cannot be provided by a less qualified medical provider. The enrollee continues to require wound care by 
skilled nursing care for the time being. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve 5 additional home health skilled nursing visits.  
 
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 pay for a crown porcelain/ceramic (D6740) provided on April 4, 
2023. 
 
You asked the Plan to pay for a crown. You say that this should be covered. The Plan denied your request. The 
Plan says this is not a covered service. 
 
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 pay for a crown 
porcelain/ceramic (D6740) provided on April 4, 2023.