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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you need therapy to regain her functionality. 
The Plan denied your request. The Plan says you do not require services that cannot be provided at the current 
inpatient rehab facility. 
 
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 physician reviewer 
found that the most recent therapy notes indicate you require maximum assistance for ambulation with a 
walker. You also require maximal assistance for bed mobility, and moderate assistance for transfers. You are 
able to use a wheelchair for mobility with minimal assistance. You continue to receive nutrition via a feeding 
tube. You have stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation 
facility (IRF).  You continue to require skilled nursing and skilled therapy services. Although you are making 
slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. There are 
no services offered at a SNF that are not offered at an inpatient rehab facility.  Therefore, an admission to a 
SNF for inpatient skilled rehab services 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) services. 
 
You asked the Plan to pre-approve the myocardial perfusion imaging (MPI) services. You say that the 
requested test is appropriate for the enrollee's condition. You say that the enrollee's diagnosis code and the 
medical records support the need for the requested test. The Plan denied your request. The Plan says the results 
of an ECG were unclear in regard to whether or not there is a decreased blood supply to the enrollee's heart. 
The Plan says that the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is covered for certain 
indications and when 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 
(MPI) services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found that, although one of the ICD 10 codes listed on the nuclear stress test request is dyspnea on exertion, the 
visit note of October 23, 2020 does not record any complaints of anginal chest pain, dyspnea on exertion or any 
other cardiac symptoms.   
 
There is also no record of limitation of exercise capacity or inability to walk on a treadmill which might require 
at chemical stress nuclear test. His EKG has some T wave changes from a 2008 EKG but no reported bundle 
branch block, drugs induced EKG changes or evidence of significant left ventricular hypertrophy which would 
limit the interpretation of a standard exercise EKG stress test which would then require the additional nuclear 
imaging by CMS criteria. Isolated mild sinus bradycardia is not an indication for nuclear stress testing. He also 
has no history of prior CAD, PCI, CABG or congestive heart failure. 
 
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 (MPI) services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare criteria for SNF 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has 
stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at 
a lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, she could not tolerate daily skilled services and care can be provided at a lower level of care than a 
skilled nursing facility.  
 
The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. 
She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is 
not near her baseline but she cannot tolerate daily therapy and can receive services at a lower level of care. 
Admission to a SNF for inpatient skilled rehab services 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a new patient office visit (99204, G8427) provided on June 3, 2020. 
 
You asked the Plan to pay for a new patient office visit. You say that the provider of this service has a different 
specialty that the provider of previous services. The Plan denied your request. The Plan says that this should 
not be billed with a new patient code. 
 
The Plan must follow Medicare rules. Medicare rules say that to interpret the phrase 'new patient' to mean a 
patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., 
surgical procedure) from the physician or physician group practice (same physician specialty) within the 
previous 3 years. You can find this rule in The Medicare Claims Processing Manual, Chapter 12, Section 
30.6.7.  
 
We looked at the file and Medicare rules. The record shows that the new patient visit at issue was denied due to 
hospital care (99222) provided on May 1, 2020. However, the provider of the service at issue and the provider 
of the hospital care have different physician specialties. Based on this information, we decided that Medicare 
rules for coverage of a new patient office visit have been met. Therefore, we decided that the Plan has to pay 
for a new patient office visit (99204, G8427) provided on June 3, 2020.  
 
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 PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is necessary. The Plan denied your 
request. The Plan says the scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer 
found the patient underwent CT chest on April 16, 2020, which demonstrated a lung nodule concerning for 
malignancy. PET scan on May 29, 2020, revealed the same. The patient underwent bronchoscopy with biopsy 
which was negative for malignancy. On August 26, 2020, the patient underwent a second PET scan for 
surveillance. A third PET scan was requested. Considering the tests completed thus far do not suggest 
malignancy in this case, surveillance with additional PET scans is not justified. Therefore, this request for such 
will be considered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that while you do not have diabetes, you have very 
severe issues with your feet which limits your mobility and would be helped by these inserts. The Plan denied 
your request. The Plan says this item is not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services. 
 
You asked the Plan to pre-approve the MRI services. You say that the requested MRI is medically necessary. 
The Plan denied your request. The Plan says the guidelines for coverage are not supported by the records 
provided. 
 
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 services. Our reviewer says 
that the requested cervical MRI is not medically reasonable or necessary. Our physician reviewer found the 
enrollee has a history of neck pain. The only clinical information submitted was a report for a barium swallow 
and a cervical spine x-ray. Both of these results suggested diffuse idiopathic skeletal hyperostosis. There is no 
history or physical exam documented. There is no documentation of a trial of conservative treatment. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee cannot walk steadily and the 
records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee's 
needs are more appropriate for a long term care facility. The Plan says that the enrollee is medically stable and 
there is no clinical evidence of any unstable medical or rehabilitation conditions requiring a SNF 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the 
SNF. The enrollee was at a moderate assist level with functional mobility. The enrollee required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs.  
 
There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional logisticare mileage. 
 
You asked the Plan to pre-approve additional logisticare mileage. You say that you require additional trips for 
medical appointments. The Plan denied your request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. You are requesting 
an additional 119 miles for a total of 194 miles. Your benefit only allows seventy-five (75) miles. You have 
exceeded your benefit limit. Therefore, we decided that the Plan does not have to pre-approve additional 
logisticare mileage.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs to see a rehab 
doctor three times per week nor does she need an intensive rehab team. The Plan say that the enrollee can 
safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 enrollee was admitted to the acute care hospital on October 29, 2020, with a 
periprosthetic fracture of her distal right femur. On November 2, 2020, the enrollee was able to walk 20 feet 
with minimal assistance. Physical therapy and occupational therapy have recommended therapies 3 times per 
week for 4 weeks. 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. The documentation does 
not support that the enrollee requires at least 3 hours a day, 5 days a week or 15 hours over 7 consecutive days, 
of therapy 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee is medically stable and does not have any 
inpatient skilled needs at this time. The Plan says that the enrollee's need at this time is only supportive 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy, speech 
therapy, and occupational therapy. The enrollee was at a moderate to maximal assist level with functional 
mobility, including gait to a few feet with handheld assistance. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs.  
 
There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or 
intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee lives alone and has balance 
issues. You say that the enrollee needs a SNF level of care to work on balance, medication management, and 
gait. The Plan denied your request. The Plan says the medical records show that the enrollee is medically stable 
and no longer requires skilled nursing or skilled therapy on a daily basis. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically 
and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF) with good progress.  
The enrollee is able to ambulate up to 400 feet and is able to accomplish activities of daily living 
independently.   
 
Although the enrollee has made good progress with therapy, there is no indication that transfer to a skilled 
nursing facility is required.  The enrollee can continue to receive skilled rehab services at a lower level of care. 
admission to a SNF for inpatient skilled rehab services 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) 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 the medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says the records show the enrollee has not 
completed the full course of care in the hospital. 
 
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 has a history of diabetes and hypertension and was admitted to the acute 
care hospital on October 12, 2020 following a head injury. The enrollee suffered an odontoid process fracture, 
a frontal brain contusion, a left orbital fracture, and a forehead laceration. The enrollee underwent 
neurosurgical repair, with elevation of a depressed skull fracture. A tracheostomy was placed. On November 8, 
2020, the enrollee's prognosis "must be considered guarded." On November 9, 2020, a formal mental status 
examination and motor examination could not be performed secondary to the enrollee's level of consciousness. 
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 he 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, LTACH 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 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.