Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you can be safely and effectively treated in a skilled nursing facility. 
 
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 does not require the intensity of services provided at an IRF.  
Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with 
regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdomen and pelvis (74174) and CTA of the chest (71275). 
 
You asked the Plan to pre-approve a CTA of the abdomen and pelvis and CTA of the chest. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CTA of the abdomen and pelvis and 
CTA of the chest. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found absent the explanation for the requests for CTA of the chest and abdomen and pelvis, medical necessity 
for the requested exams has not been established by the requesting physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CTA of the abdomen and pelvis and CTA of the chest have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) 
of the abdomen and pelvis (74174) and CTA of the chest (71275).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac hemodynamic monitoring (33289, C2624). 
 
You asked the Plan to pre-approve cardiac hemodynamic monitoring. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 cardiac hemodynamic monitoring. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac hemodynamic monitoring have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cardiac hemodynamic monitoring (33289, C2624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Herceptin regimen (J9355). 
 
You asked the Plan to pre-approve a Herceptin regimen. You say that the requested medications are necessary. 
The Plan denied your request. The Plan says they are not responsible for covered routine costs associated with 
clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a Herceptin regimen as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve a Herceptin regimen (J9355).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received 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 does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of excess skin (15830). 
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because you have 
excess skin after surgery. The Plan denied your request. The Plan says this surgery is not medically necessary 
and is cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that 
there is no evidence of a typical functional impairment associated with mild to moderate excess skin of the 
abdomen.  The photographs do not show evidence of a severe condition of overlap that would be considered 
removal based on a reconstructive principle. Our reviewer found the requested surgical intervention does not 
satisfy Medicare medically necessary criteria. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the removal of excess skin (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated knee orthosis (L1820). 
 
You asked the Plan to pay for the orthosis. You say that the enrollee requires the orthosis. The Plan denied your 
request. The Plan says there must be objective evidence of weakness or deformity of the knee. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis with condylar pads and joints 
with or without patellar control (L1820) are covered for ambulatory beneficiaries who have weakness or 
deformity of the knee and require stabilization. If these criteria are not met, the orthosis will be denied as not 
reasonable and necessary.  
 
The documentation does not show objective findings of weakness or deformity. Therefore, we decided that the 
Plan does not have to pay for a prefabricated knee orthosis (L1820).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission after knee surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you would like reconsideration 
because inpatient admission will be medically necessary. The Plan denied your request. The Plan says the 
documentation did not specify why inpatient admission would be needed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found there is no documentation in the record showing that the admitting 
physician reasonably expects that the patient's necessary hospital care will span two midnights. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
inpatient admission for the approved right total knee arthroplasty at this time. Therefore, this request for 
inpatient admission 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient admission after knee surgery.
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 requesting an expedited appeal for the 
denied rehabilitation. The Plan denied your request. The Plan says the services that you require can be given in 
a skilled nursing facility. 
 
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 you have no complex nursing or rehabilitation needs. Our reviewer says that 
treatment by multiple therapies in an intensive rehabilitation program is not required.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee s receiving appropriate in-patient acute care. 
 
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. The short-
term acute care hospital can provide for all the patient's present inpatient care needs and the patient is receiving 
an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for 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 for the enrollee.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that the admission is medically necessary. The Plan 
denied your request. The Plan says that the admission 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 the 
admission is medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
August 20, 2020 after a fall with ankle fracture. She underwent surgical repair of the right ankle. She is non-
weight bearing on the right lower extremity, but a period of therapy to provide strength, endurance, and transfer 
training is necessary. The enrollee requires skilled therapy services on a daily basis to establish a maintenance 
program and/or to prevent deterioration of her condition. As a practical matter, the enrollee requires the 
necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled 
nursing facility (SNF) admission.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on August 14, 2020 and underwent left knee revision surgery. The physical therapy note on August 31, 2020 
states he needs supervision to walk 60 feet with a rolling walker. He needs supervision with grooming at sink, 
bathing, dressing, and toilet transfers. He does not have skilled nursing or skilled therapy needs. He does not 
require these services on a daily basis. As a practical matter, the enrollee does not require the necessary 
services on an inpatient basis at the SNF level of care. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a portable parenteral nutrition infusion pump (B9004) provided on 
January 11, 2020 through January 15, 2020. 
 
You asked the Plan to pay for the portable pump. You say that you would like reconsideration because this 
pump is medically necessary. The Plan denied your request. The Plan says that the documentation submitted 
does not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid physician order and proof of delivery for the supplies provided in this case. 
Therefore, we decided that the Plan has to pay for a portable parenteral nutrition infusion pump (B9004) 
provided on January 11, 2020 through January 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vaccine for tetanus, diphtheria toxoids and acellular 
pertussis (TDAP) (whooping cough) for injection into muscle (90715) provided on March 18, 2020. 
 
You asked the Plan to pre-approve the TDAP vaccine. You say that per the plan representative you spoke to 
over the phone these two lines need to be resubmitted to Part D Pharmacy coverage. The Plan denied your 
request. The Plan says the TDAP shot is only covered under the Part D prescription drug benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve vaccine for tetanus, diphtheria toxoids and acellular pertussis (TDAP) 
(whooping cough) for injection into muscle (90715) provided on March 18, 2020.  
 
Benefits for the TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the walking boot provided on March 2, 
2020. 
 
You asked the Plan to waive the copayment for the DME. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the walking boot provided on March 2, 2020. You have been asked 
to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $220.46. The total you owe is 
$44.09 ($220.46 x 20% = $44.09). 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 the walking boot 
provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device was necessary to 
prevent deep vein thrombosis. The Plan denied your request. The Plan says pneumatic compression device is 
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. PCDs billed by 
E0675 are also not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).