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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
August 29, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has been showing 
improvement with the therapy and should be allowed to continue. The Plan denied your request. The Plan says 
the enrollee no longer requires daily skilled services beyond the date in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 70-year-old 
male with pneumonia, compression fracture, respiratory failure, dementia, diabetes and BPH admitted to the 
SNF on June 16, 2020. From a nursing perspective, the beneficiary received oral medications.  The beneficiary 
had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the beneficiary 
received PT, OT and ST in the SNF.  By the dates in question, he was at a minimal to moderate assist level 
with functional mobility. He required varying assist with ADLs.  He tolerated a restricted diet and thickened 
liquids. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to continue therapy to reach your goal 
of returning home. The Plan denied your request. The Plan says that your rehab and medical 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 above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) 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. The Plan denied your request. The Plan says Medicare coverage 
criteria have not been met for admission to an acute IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee's medical status does not currently require intensive physician and nursing oversight 
only in an IRF. Our physician reviewer also found that the enrollee may benefit from multiple therapies such as 
physical and occupational therapy, but the documentation does not support that the enrollee's functional status 
requires an 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says non-
thermal RF modalities are not covered. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that you have chronic low back pain and has lymphoma. You have failed conservative therapy. 
You have had a series of lumbar medial branch blocks (MBBs) with pain relief of between 50% and 60%. You 
did not achieve 80% pain relief from the local anesthetic/steroid injections.  Therefore, you do not meet the 
coverage criteria, and the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428 and A0425) provided on January 
3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says a sequela code cannot be listed  as the 
primary, first listed or  principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes A0428 and A0425 are not supported in the record. Specifically, the first listed 
diagnosis code on the claim is sequela T82.198S. Sequela codes should be listed second after the diagnosis 
code for the condition or nature of the sequela. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0428 and A0425) provided on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response services provided on June 10, 2020. 
 
You asked the Plan to pay for the ambulance response services. You say that you had oozing from your wound 
following a excision of an epidermoid cyst on your neck. You say that you were encouraged not to follow-
through with the transfer by ambulance, as their team assured you additional medical intervention was not 
necessary. You say that your family had to take you to for medical intervention later in the evening. The Plan 
denied your request. The Plan says ambulance non-transport services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 10, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response services provided on June 10, 
2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda 25 mg/ml for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that use of Keytruda with Carboplatin and Nab-Paclitaxel is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found this drug can be 
approved per the NCCN compendia. The enrollee has stage IV adenocarcinoma of the lung, with no actionable 
mutations. Carboplatin/Taxol/Keytruda can be approved as a clinical variant. The provider did not ask for 
Abraxane. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda 25 mg/ml for the enrollee.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's care can be provided safely at a less intensive setting 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 above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual swingaway, adjustable height armrest, and 
power standing feature for a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested chair was 
configured to meet your needs. The Plan denied your request. The Plan says the denial of authorization for 
these components is correct. The Plan also says that they have approved the power wheelchair itself and all 
other requested components, so only the manual swingaway (E1028), adjustable height armrest (E0973), and 
power standing feature (E2310) remain denied. 
 
The Plan follows Medicare rules. Medicare rules say that an adjustable arm height option and swingaway may 
be covered if medically necessary. The rules also say that a power standing feature is not covered by Medicare. 
 
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 power wheelchair accessories. Our 
reviewer says that you do not meet the Medicare criteria for the requested wheelchair accessories. Our 
physician reviewer found the adjustable height armrest is not medically necessary as it exceeds your medical 
needs. The needed armrest is already included in the approved power seating system and this additional 
component is not needed. The requested manual swingaway component is also already included in the 
approved residual limb support system and would exceed your medical needs. The documentation submitted 
does not indicate that you are unable to perform a slide board transfer with the approved system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a manual swingaway, adjustable height armrest, and power standing feature 
for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafting (21210 x2) and dental implants (21248 
x2). 
 
You asked the Plan to pre-approve bone grafting and dental implants. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve bone 
grafting (21210 x2) and dental implants (21248 x2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EGD, flexible, transoral; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure) (CPT Code 43235). 
 
You asked the Plan to pre-approve the EGD. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 EGD. Our physician reviewer found 
the medical records as provided do not meet the requirements listed in the LCD for Medicare coverage of EGD. 
Specifically, the patient has not demonstrated an adequate trial of optimally dosed proton pump inhibitor (PPI) 
therapy of 8-12 weeks duration, nor does the patient's globus sensation qualify as "dysphagia." The patient's 
provided history supports high likelihood of functional symptomatology, for which alternative imaging 
strategies may be pursued in evaluation of the patient's symptoms, including potential hydrogen (pH) testing 
and manometry. 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve EGD, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or 
washing, when performed (separate procedure) (CPT Code 43235).
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 the enrollee is medically stable and ready 
to discharge to an LTACH. You say that the enrollee is expected to require at least an additional 25-day length 
stay in an acute care facility. You say that the enrollee does not need any other setbacks with her care and is 
high risk for decline and more complications without the extended care she needs. The Plan denied your 
request. The Plan says LTACH care is not medically necessary. 
 
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 was admitted to the acute care hospital on August 11, 2020 with 
respiratory failure due to pneumonia. Multiple rounds of antibiotics have been administered. The hospital 
course has been complicated by encephalopathy, atrial fibrillation, and renal failure. On September 27, 2020, 
the enrollee could open her eyes, but was not moving her extremities. An EEG showed generalized slowing 
consistent with cerebral dysfunction. The enrollee is receiving acute hospital care, and acute care services have 
not been denied. The documentation does not support that the enrollee in this case requires services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. The clinical 
assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and 
improve with, services that are available at an LTACH. 
 
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 Xcopri Pak 12.5-25 for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not have a Part D benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xcopri Pak 12.5-25 for the 
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 
(CPT Code 22513). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found the criteria has not been met. There are no imaging studies that show there is a recent spine compression 
fracture. Also, recent literature shows kyphoplatsy is not more effective than sham or conservative measures. It 
is not needed in this case. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; thoracic (CPT Code 22513).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the enrollee has new 
symptoms and that the myocardial perfusion imaging is medically necessary. You say that the enrollee tried the 
exercise test and were unable to complete it due to severe diabetic neuropathy. The Plan denied your request. 
The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 myocardial perfusion imaging. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found a nuclear stress test June 3, 2015 was reported to be normal. An electrocardiogram on 
January 21, 2020 documents a normal sinus rhythm and no ischemic changes. Coronary calcifications are noted 
on a CT scan July 2, 2020. A clinic note dated August 25, 2020 documents exertional dyspnea but no chest 
discomfort and a normal cardiac and pulmonary physical exam. The enrollee was unable to adequately 
ambulate on a treadmill due to neuropathy. Based on the records the patient has increased coronary risk, 
exertional dyspnea concerning for a coronary ischemic equivalent and inability to adequately ambulate on a 
treadmill.  In this circumstance, some sort of pharmacologic stress test is reasonable, appropriate, and 
considered standard accepted practice in the medical community. Coverage criteria above for a nuclear stress 
test are met and are supported by current guidelines. 
 
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 myocardial perfusion imaging have been met. Therefore, we decided that 
the Plan has to pre-approve myocardial perfusion imaging.  
 
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.