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 services are medically necessary for the enrollee 
who is in need of therapy services and has balance issues. The Plan denied your request. The Plan says the 
enrollee can safely receive the services needed in another setting such as a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 
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 is medically stable. There are no acute rehab nursing needs identified or 
documented. While the enrollee may benefit from physical and occupational therapy, their rehab needs can be 
provided in a lower intensity and alternate setting such a skilled nursing facility.  
  
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgery and related services received on November 18, 2022. 
 
You asked the Plan to pay for the surgery and related services. You say that you do not understand why this is 
not covered if everything else prior to this was covered. The Plan denied your request. The Plan says that the 
claim is not payable as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You received the surgery and related services by a contract provider. The file does not show that the Plan 
provided notice that the surgery and related services would not be covered. Under Medicare rules, this means 
the surgery and related services is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for the surgery and related services received on November 18, 2022 minus any cost share 
requirement.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on January 4, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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.  
We find that code A4239 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have 
to pay for procedure code A4239 provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the extractions, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210 x 2) and the panoramic radiographic image (D0330) provided on August 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that your dental benefit maximum 
allowance has already been exhausted for this calendar year. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, the Plan has not provided substantive evidence that demonstrates the dental 
benefit maximum allowance had been previously exhausted for this calendar year. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay 
for the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) and 
the panoramic radiographic image (D0330) provided on August 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of ankle joint. 
 
You asked the Plan to pre-approve the MRI of the ankle joint. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the service is not reasonable and necessary at this stage 
of the work-up. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI of the ankle joint. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found that during the encounter 
on April 18, 2023, there was left ankle pain noted. The x-ray results were pending. Physical exam of the 
extremities revealed no edema. There was no detailed physical exam of the left ankle. Medical necessity of the 
MRI of the left ankle has not been established in the records provided. 
 
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 MRI of the ankle joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of ankle joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee continues to need aggressive inpatient 
rehabilitation to return to his prior level of independence. The Plan denied your request. The Plan says 
admission to an IRF is not medically 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 that 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. While the enrollee may have a need for physical 
therapy 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 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 18, 
2022, to December 19, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you contracted COVID-19 which 
extended your 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 $0 
copayment per day for days 1-20 of each benefit period. Your contract with the Plan also clearly says that you 
must pay a $160 copayment per day for days 21-100 of each benefit period. The Plan confirmed that you had utilized 13 SNF days from October 28, 2022, to November 10, 2022. During 
your SNF stay from November 18, 2022, to December 19, 2022, the first seven days assessed a $0 copayment 
per day. You have been asked to pay a $160 copayment per day for the remaining 24 days of SNF care. You 
have been asked to pay a total of $3,840 ($160 copayment per day x 24 days = $3,840). This item/service falls 
within the skilled nursing facility 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 SNF stay provided from November 18, 2022, to December 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90791 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the place of 
service was not billed correctly. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90971 was not billed with a valid place of service code. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 90791 billed for date of service May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the items were not inclusive to any procedure. 
The Plan denied your request. The Plan says the services are not separately payable. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that the billed services were used in a SNF. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the wound care supplies billed for date of service November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a high frequency chest wall oscillation device (HFCWOD) 
on February 28, 2021. 
 
You asked the Plan to pay for a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
  
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 a HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records in this case do not document a 
diagnosis of cystic fibrosis or bronchiectasis which has been confirmed by a high resolution, spiral, or standard 
computed tomography (CT) scan or the diagnosis of a neuromuscular disease such as post-polio, acid maltase 
deficiency, anterior horn cell disease, multiple sclerosis, quadriplegia, hereditary muscular dystrophy, a 
myotonic disorder or other myopathy or paralysis of the diaphragm. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pay for a high frequency chest wall oscillation device (HFCWOD) on February 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 29, 2022, to 
September 27, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 30, 2022. The NOA was not received by the Plan until October 28, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 29, 2022, to September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the enrollee has ischemic 
cardiomyopathy and heart failure. He has had recurrent hospitalizations for worsening heart failure, despite 
standard medical therapy. This device is medically necessary. The Plan denied your request. The Plan says the 
Barostim Neo device is considered unproven and is not medically necessary. Experimental procedures and 
items are those items and procedures determined by our plan and Original Medicare to not be generally 
accepted by the medical community. 
 
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 the Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, the CCM system is not medically necessary for this enrollee. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9379 billed for date of service October 21, 
2022. 
 
You asked the Plan to pay for procedure code S9379. You say that the claim should be processed in-network. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code S9379 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9379 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9379 billed for date of service October 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 SI joint fusion. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records do not show any evidence of SI joint instability, fracture, or lesion. Si joint fusion 
for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97602 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 97602. You say that the medical records support the charges. The 
Plan denied your request. The Plan says procedure code 97602 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97602 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97602 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97602 billed for date of service October 6, 2022.