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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare guidelines for an IRF admission. 
 
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 do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
continue to have a need for skilled therapy; however, you do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says based on Medicare 
guidelines, the LTACH services requested do not meet the requirements for approval. 
 
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 enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says they have not received records showing that the enrollee meets the criteria 
for the medication requested. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step alternatives Inflecta or Renflexis. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
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 you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the skilled nursing facility (SNF) services requested do not meet the requirements for approval. 
 
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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the non-quantified 
weight loss together with a CT scan of the chest in 2022 without a submitted report do not provide a valid 
request to establish the medical necessity of the requested CT of the chest. 
 
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 computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service November 24, 
2022, to November 25, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 code 99233. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee has a history of hypertension 
who presented with dysarhtria and was found to have encephalopathy from metabolic derangements and severe 
hyponatremia with peritoneal carcinomatosis. The documentation does not support a detailed history or a 
medical decision making of high complexity. Therefore, code 99233 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 for date of service November 24, 2022, to November 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala trio therapy system. 
 
You asked the Plan to pre-approve the Cala trio therapy system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is considered experimental. 
 
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 Cala trio therapy system. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this item is considered 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 the Cala trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Cala trio therapy system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for date of 
service April 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for diabetes problems. The 
Plan denied your request. The Plan says the billed codes cannot be verified. 
 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 codes 96365 and 96366, were billed for outpatient intravenous insulin therapy. There is a 
more accurate code available to describe the services provided. The records show that orders were placed for 
the refilling and maintenance of a portable pump (code 96521). However, the records do not show this service 
was provided.  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 codes 96365, 96366, 
and 96521 billed for date of service April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
and accessories. (E0955, E1002, E1012, E1028, E2209, E2311, E2361, E2607, E2620, K0108, K0856). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that this is medically 
necessary for the enrollee.  The Plan denied your request. The Plan says the notes do not show that the enrollee 
has a medical need for the power tilt or power recline.  
 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 the durable medical equipment (DME). 
Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Although the 
enrollee's condition may meet criteria for a power wheelchair, the criteria for this specifically requested power 
wheelchair with multiple power options including power tilt and recline are not met. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option and 
accessories. (E0955, E1002, E1012, E1028, E2209, E2311, E2361, E2607, E2620, K0108, K0856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 1 power mobility device. 
 
You asked the Plan to pre-approve the power mobility device. You say that the power mobility device is not 
medically necessary.  The Plan denied your request. The Plan says you are moving to an independent living 
facility. You say that you need a power scooter to get to the dining room. You also say that you are not able to 
walk far with your walker.  
 
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 the power mobility device. Our 
physician reviewer found there is a lack of clinical documentation indicating the patients level of mobility and 
physical examination findings, specifically with regards to motor strength in the upper and lower extremities. 
There is no indication that you cannot use a cane or walker for assistance with mobility or propel a manual 
wheelchair. There is also a lack of information as to whether you can safely operate the requested group 1 
power mobility device. Therefore, the group 1 power mobility device is not medically 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 power mobility device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the group 1 power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the resin-based composite (D2335), endodontic therapy 
(D3310) and a prefabricated post and core in addition to crown (D2954) provided on April 26, 2023 by an out-
of-network (OON) provider. 
 
You asked the Plan to fully pay for the  dental services. You say that your dental issues were caused by 
radiation to your neck due to thyroid cancer treatment. You say that you are requesting that your dental care be 
paid for by your medical insurance. The Plan denied your request. The Plan says a prefabricated post and core 
in addition to crown is not a covered benefit. The Plan also says you are responsible for the difference between 
the OON providers charges and the Plans payment for the resin-based composite and endodontic therapy. 
 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. 
 
These services are not covered under the medical benefit; however, the Plan offers a dental benefit in excess of 
Medicare coverage. The prefabricated post and core in addition to crown (D2954) is not covered under the 
supplemental benefit. In addition, the Plan covered the resin-based composite (D2335) and endodontic therapy 
(D3310) at the out-of-network rate. You are only responsible for the difference between the out-of-network 
providers charges and the Plans payment for the resin-based composite (D2335) and endodontic therapy 
(D3310). Therefore, we decided that the Plan does not have to fully pay for the resin-based composite (D2335), 
endodontic therapy (D3310) and a prefabricated post and core in addition to crown (D2954) provided on April 
26, 2023 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 25, 2023, billed with 
evaluation and management (EM) code 99204. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 25, 2023, billed with evaluation and 
management (EM) code 99204.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for a second opinion with a gynecology 
oncologist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that there are no gynecologic oncologists outside of 
your practice and you do not have appropriate trial options for the enrollee that the requested facility can 
provide to the enrollee. The Plan denied your request. The Plan says the enrollee must use network providers to 
get her medical care and services. There are gynecology oncologists available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit for a second opinion with a gynecology oncologist to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on May 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery payment for the procedure (20610) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (99213) provided on May 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
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 the enrollee is currently receiving approved care in an acute facility. There are no 
specific treatments that the LTACH will offer that are not currently being provided in the acute care hospital. 
 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 long term acute care hospital (LTACH) services.