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 this is needed for recovery. The Plan denied your 
request. The Plan says this would exceed your needs. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a syncopal episode and was treated non surgically for a pelvic fracture. Medical conditions are 
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate needle biopsy provided on May 18, 2020 billed 
with one unit of code G0416-TC and five units of G0416-91-TC. 
 
You asked the Plan to pay for the prostate biopsy as billed. You say that this was correctly billed and should be 
paid. The Plan denied your request. The Plan says the MUE of this code is one with a MAI of 2, meaning that it 
is an absolute date of service edit and there is no instance in which the MUE can be exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code G0416 is 1. You billed 6 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the prostate biopsy as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the prostate needle biopsy provided on May 
18, 2020 billed with one unit of code G0416-TC and five units of G0416-91-TC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-
week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
 
 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on February 3, 2020. 
 
You asked the Plan to pay for the DME. You say that the medical records prove the medical necessity of the 
items billed. The Plan denied your request. The Plan says with the information the Plan has, the Plan cannot 
determine if a physician?s order was given, how the member came to you or whether the services are necessary. 
All providers are required to furnish necessary information to the health Plan when requested. After multiple 
attempts to obtain information, none was received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to 
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the 
DME items have not been met. Therefore, we decided that the Plan does not have to pay for the DME provided 
on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 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 your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. You were admitted for COPD exacerbation. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower bench. 
 
You asked the Plan to pre-approve a shower bench. You say that you are in need of a shower bench so you do 
not fall since you do not have strength in legs. The Plan denied your request. The Plan says this is a 
convenience item and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a shower bench.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial and 
lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT Code 27447) for the 
enrollee.  
 
You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this surgery. 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 this surgery. Our reviewer says that Medicare coverage 
criteria are not met. Our physician reviewer found there is no radiographic evidence of loosening or cyst 
formation. There is no instability. Revision of components is not indicated from the records. Medicare 
coverage criteria 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 this surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial and lateral 
compartments with or without patella resurfacing (total knee arthroplasty) (CPT Code 27447) for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on September 4, 2020. 
You asked the Plan to pay for the laboratory services. You say that your physician requested the lab work for 
after care hospital services. The Plan denied your request. The Plan says that authorization was not obtained. 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not identified the network status of the referring provider. 
Therefore, we decided that the Plan has to pay for the laboratory services provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmented pneumatic compressor (E0651 and E0667) 
provided on August 10, 2020. 
 
You asked the Plan to pay for the segmented pneumatic compressor. You say that you would like 
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the 
only time that a segmented, calibrated gradient pneumatic compression device would be covered is when the 
individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression 
treatment using a non-segmented device. 
 
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 the segmented pneumatic compressor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there was no documented reason why the member would require a 
segmented device as compared to a non-segmented device as 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 the segmented pneumatic compressor have not been met. Therefore, we decided 
that the Plan does not have to pay for the segmented pneumatic compressor (E0651 and E0667) provided on 
August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care from December 12, 2020, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 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 care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing 
services are identified. There are no required skilled therapy services are identified. 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 
SNF care from December 12, 2020, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will not get intensive rehab in a nursing home. 
The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77301, 77525, 77522, 
77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is 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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77301, 77525, 77522, 77523).
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee is currently medically 
stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. He may benefit from further therapy but does not require an intensive 
therapy program in an IRF. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested drug. 
 
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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug, Injectafer is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of Iron deficiency anemia, unspecified. The 
documentation does not support a trial of oral iron supplementation. The documentation does not support that 
oral iron supplementation would likely be less effective, and/or would likely have adverse effects for the 
enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 it is felt that LTACH care would be best. 
The Plan denied your request. The Plan says the criteria for LTACH care are not met. 
 
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 patient is a 66-year-old male who was admitted to the current acute care hospital 
with acute respiratory failure and pneumothorax first requiring high flow oxygen then mechanical ventilation. 
He was treated for pneumonia with antibiotics and was also treated with steroids. He had mental status changes 
which were monitored and currently slowly improving. PEG tube was placed. He currently is also receiving 
pulmonary toilet once daily. Imaging shows improving pneumonia. 
 
The patient appears to be improving and more stable, however, they appear to require short term additional 
acute care services to further improve which can be safely completed at the current facility. The patient does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the patient requires that are not already available and covered at the current 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.