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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of atrial fibrillation, peripheral vascular disease, a right above-the-knee amputation and a prior 
stroke who presented to the acute hospital on 10/24/2020 with weakness and pneumonia. She was treated in the 
hospital with intravenous antibiotics and a thoracentesis. A CT scan of the chest was concerning for a primary 
lung cancer. She also suffered atrial fibrillation with rapid ventricular response in the hospital which responded 
to treatment with diltiazem. Notes also indicate she has cognitive dysfunction concerning for dementia. She is 
weak and deconditioned and is working with physical and occupational therapy. She uses a wheelchair for 
mobility and is maximum assist for transfers and moderate to maximum assist for activities of daily living. She 
was noted to be lethargic and fatigued after a 22-minute session with occupational therapy on 11/03/2020. 
Notes indicate she fatigues quickly with therapy. She is reported to be medically stable for discharge. Transfer 
to an acute inpatient rehabilitation facility is requested.  
 
Based on the medical records provided 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 enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on March 3, 2020 billed with 
code 34812. 
 
You asked the Plan to pay for the surgical services. You say that this should be paid. The Plan denied your 
request. The Plan says this add-on code is not eligible for payment without a primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that add-on codes are only payable if billed with an 
appropriate primary code. Add-on codes cannot be paid if it is the only code billed.  
 
CPT code 34812 is defined as Open femoral artery exposure for delivery of endovascular prosthesis, by groin 
incision, unilateral (List separately in addition to code for primary procedure).  
 
This definition shows that this is an add-on code. This code was billed without any primary procedure. As such, 
the rules for payment of this code are not met. Therefore, we decided that the Plan does not have to pay for the 
surgical services provided on March 3, 2020 billed with code 34812.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that care can be provided 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 the enrollee's condition does not 
meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your therapy needs can continue to be provided at a lower level 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 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 sepsis and surgical 
management of perforated diverticulitis. Your medical problems are stable. There are no identified problems 
that need inpatient medical management. 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. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy 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. Our physician reviewer found that your 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.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 the documentation does not support 
that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services from October 9, 2020, through 
October 17, 2020. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 appears to be more stable at the time of this request, but would have likely 
required less than 25 additional days of acute care services which could have likely been completed at the short 
term acute care facility. The patient does not require services at the LTACH that they were not available at the 
short term acute care facility. There are no services at the LTACH that are not already available and covered at 
the short term acute care facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. 
 
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 LTACH services from October 9, 2020, through October 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 Leiden Variant testing, F2 testing, MTHFR testing, 
and molecular pathology procedure 
 
You asked the Plan to pre-approve F5 Leiden Variant testing, F2 testing, MTHFR testing, and molecular 
pathology procedure. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing of the Factor V Leiden (FVL) variant in 
the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR gene are only covered for 
pregnant enrollees. The rules also say that Notation coagulopathy is a non-covered test. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant. In 
addition, the requested molecular pathology procedure is Notation coagulopathy. Notation coagulopathy is a 
non-covered test. Based on this information, we decided that Medicare rules for coverage of F5 Leiden Variant 
testing, F2 testing, MTHFR testing, and molecular pathology procedure have not been met.  
 
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve F5 Leiden Variant testing, F2 testing, 
MTHFR testing, and molecular pathology procedure
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee would likely be 
able to fully participate in and benefit from intensive rehabilitation therapy. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery for insertion of a Superion Interspinous Spacer. 
 
You asked the Plan to pre-approve surgery for insertion of a Superion Interspinous Spacer. You say that this 
surgery is medically necessary. The Plan denied your request. The Plan says this surgery and device are not 
covered by Medicare. 
 
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 surgery for insertion of a Superion 
Interspinous Spacer. Our reviewer says that this service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the spacer is considered experimental. More research is needed to 
show safety and efficacy. 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 surgery for insertion of a Superion Interspinous Spacer have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgery for insertion of a Superion 
Interspinous Spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on June 
21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred to 
another facility for a surgery and did not know you would owe an additional copayment. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for each admission for inpatient hospital care.  
 
You have been asked to pay a $295 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided on June 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA) of 
varicose veins. 
 
You asked the Plan to pre-approve the ERFA procedure. You say that the enrollee requires this treatment. The 
Plan denied your request. The Plan says the enrollee's disease severity is C5 and venous ultrasound shows that 
the diameter of the greater saphenous vein is 3.3 mm and the diameter of the superficial saphenous vein is 2.8 
mm, which is below the minimum for coverage of this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that ERFA may be covered for treatment of varicose veins 
which are of a certain diameter or higher when other treatments have failed.  
 
 
 
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 ERFA procedure. Our reviewer says 
that the documentation does not show that the requested treatment is reasonable and necessary. Our physician 
reviewer found the documentation does not meet the coverage criteria. Specifically, size criteria for the veins to 
be treated are not met as their diameter is below the minimum. Additionally, as the patient notes that the 
previous ablations aggravated her symptoms and there is no documentation of adequate arterial perfusion to the 
lower extremities, the medical necessity/appropriateness of the treatments in question are also not supported by 
the documentation. 
 
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 ERFA procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous radiofrequency ablation (ERFA) of varicose veins.
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 you are unable to fully take care of yourself at home. 
You say that you should have gone to rehab from the hospital. The Plan denied your request. The Plan says you 
can safely receive the services in other settings. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Carbamazepine, Levetiracetam, Topiramate, Digoxin, 
Clozapine, and Haloperidol testing provided on May 11, 2020. 
 
You asked the Plan to pay for the Carbamazepine, Levetiracetam, Topiramate, Digoxin, Clozapine, and 
Haloperidol testing. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Carbamazepine, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol testing are 
not supported in the medical record. Specifically, the documentation submitted did not support that this testing 
was performed with blood sampling. Blood specimen collection is by venipuncture; however, the lab 
requisition states a urine specimen was collected. Therefore, the billed services cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of the Carbamazepine, Levetiracetam, 
Topiramate, Digoxin, Clozapine, and Haloperidol testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Carbamazepine, Levetiracetam, Topiramate, Digoxin, Clozapine, and 
Haloperidol testing provided on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0651). 
 
You asked the Plan to preapprove 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 preapprove a pneumatic compression device 
(E0651).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on May 15, 2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that this service was medically 
necessary. Your wife is paraplegic and you are not able to transport her without medics and ambulance. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services provided on May 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90791 and 90837) provided on 
December 11, 2019, through December 30, 2019. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this provider does not meet Medicare's 
standards of non-physician practitioners. 
 
The Plan must follow Medicare rules. Medicare rules say that Marriage Family Therapists are not eligible to 
enroll in Medicare.  
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, this provider is a Marriage Family 
Therapist. Marriage Family Therapists are not eligible for Medicare. Therefore, we decided that the Plan does 
not have to pay for psychotherapy services (90791 and 90837) provided on December 11, 2019, through 
December 30, 2019.