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

 
We decided that the Plan does not have to pre-approve specialty care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve specialty care. You say that you want to see this provider because you feel 
you will be diagnosed correctly, follow the correct treatment plan, and get surgery if needed. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and you can be treated within the Plan 
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 
specialty care to be provided by an out-of-network (OON) provider.
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 admission to an inpatient rehabilitation facility is 
medically necessary. The Plan denied your request. The Plan says admission to an inpatient rehabilitation 
facility 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 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.  There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of 
care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427-RH-GY, A0425-RH-GY) 
provided on January 3, 2023. 
 
You asked the Plan to pay for ambulance services. You say that this claim was denied in error. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 1, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0427-RH-GY, A0425-RH-
GY) provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that the continued 
stay is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet medical necessity requirements for approval. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric hospital 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based 
upon review the records provided it was not expected this enrollee would improve in a reasonable period of 
time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The health 
plans denial of continued inpatient psychiatric services appears appropriate. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. The reviewer is unable to find an individualized treatment plan however the entire record 
is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the 
records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of September 9, 2023, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric hospital services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan (71250) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CT scan (71250) to be provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek OON care. The Plan says there are in-network 
providers available to the enrollee that can provide the requested CT scan. 
 
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 
a computed tomography (CT) scan (71250) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing services 
provided on May 24, 2023. 
 
You asked the Plan to pay for urine PCR testing. You say that urine PCR panel testing is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says urine PCR panel testing 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 pay for urine PCR testing. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine 
culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex 
PCR urinary tract infection panel tests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine polymerase chain reaction (PCR) panel testing services provided on May 24, 2023.
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 your doctor recommends IRF services and you need 
therapy so your leg does not atrophy. The Plan denied your request. The Plan says the request 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 your 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 64612, 64642, and 64643 rendered on May 1, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 64612: 
 
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, 
hemifacial spasm) 
 
CPT 64642: 
 
Chemodenervation of one extremity; 1-4 muscle(s) 
 
CPT 64643: 
 
Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to 
code for primary procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical records properly support 
that these procedures were performed and reported correctly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 64612, 64642, and 64643 rendered on May 1, 2023.  
 
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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E2311, E2313, E2374, and E2377. We decided that the Plan does 
not have to pre-approve K0108.  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E2311, E2313, E2374, E2377, 
K0108).. You say that this is medically necessary. The Plan says that there is no medical need to control the 
power options through the joystick. 
 
We decided that the Plan has to pre-approve E2311, E2313, E2374, and E2377.  
 
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 for these accessories. Our reviewer says that the 
enrollee is non-ambulatory and requires a power wheelchair for mobility and performing his basic daily 
activities. He cannot perform pressure relief independently due to upper extremity weakness and requires a 
power wheelchair with power tilt and recline for adequate pressure relief and positioning. He requires power 
elevating leg rests for positioning of his lower extremities and lower extremity spasticity. The complexity of his 
seating and positioning needs necessitates a more complex group 3 power wheelchair base. The expandable 
controller with harness and electronic connection are necessary to operate the group 3 power wheelchair base and the three power options via a joystick. These components are required to operate 3 or more power options 
on a group 3 power wheelchair. The joystick is also necessary to operate the power wheelchair. 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve E2311, E2313, E2374, and E2377.  
 
We also decided that the Plan does not have to pre-approve K0108. 
 
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 for the fender shroud (K0108). Our reviewer says that 
the shroud is not considered medical in nature, and cannot be considered 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 K0108 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve K0108. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services coded as 99223 billed for date 
of service January 31, 2023. 
 
You asked the Plan to pay for 99223. You say that 99223 should be covered because the enrollee was seen by 
two providers of different specialties on this date of service. The Plan denied your request. The Plan says that 
99223 is denied because another initial hospital care or subsequent hospital care code was billed in the previous 
seven days by a provider of the same specialty and taxonomy code, with the same place of service, and a 
discharge service was not also billed in the previous seven days by any provider. 
 
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. The rules also say in the inpatient hospital setting, all physicians who perform an initial evaluation 
may bill the initial hospital care codes.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case file does not include proof that any other service was billed during this 
enrollee's hospital stay or on the same date of service. Without documentation of any other service being billed 
we cannot confirm whether the Plans rationale was correct in denying 99223. It also appears that the rationale 
for this denial is not supported by Medicare rules. Therefore, we decided that the Plan has to pay for the 
evaluation and management services coded as 99223 billed for date of service January 31, 2023.  
 
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 a urine polymerase chain reaction (PCR) lab test (87798) 
provided on April 28, 2023. 
 
You asked the Plan to pay for a urine PCR lab test. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the service at issue exceeded the enrollee's medical 
need. 
 
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 pay for a urine PCR lab test. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine 
culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex 
polymerase chain reaction (PCR) urinary tract infection panel tests. 
 
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 urine PCR lab test have not been met. Therefore, we decided that the Plan 
does not have to pay for a urine polymerase chain reaction (PCR) lab test (87798) provided on April 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on April 3, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this does not meet coding standards. 
 
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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 96401 is not supported. The 
record states that a Prolia injection was given subcutaneously. Prolia is not a chemotherapy substance. There is a more appropriate code to report this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure code 96401 rendered on April 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee osteoarthritis of the knee. The documentation does not support that the enrollee has tried and 
failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support that 
Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.