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 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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
November 18, 2020 with shortness of breath and weakness. The complexity of her nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There are no identified problems that need inpatient medical management. There are no 
complex nursing or rehabilitation needs. 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 this 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Health Physical Therapy services. 
 
You asked the Plan to pre-approve the Home Health Physical Therapy services. You say that you would like 
reconsideration because you are unable to attend Physical Therapy due to COVID. The Plan denied your 
request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 Home Health Physical Therapy 
services. Our reviewer says that it is not clear that you are homebound and you do not have documentation 
skilled nursing or skilled therapy needs. Our physician reviewer found the Home Health services are not shown 
to be medically reasonable and 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 Home Health Physical Therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Home Health Physical Therapy services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CTA (71275). 
 
You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says that the records do not describe the 
required imaging time frame. 
 
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 the CTA. Our reviewer says that CT 
angiography is indicated in this case for this potentially life-threatening lesion that may require high risk 
surgery for management. Our physician reviewer found this study is medically reasonable and 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 CTA have been met. Therefore, we decided that the Plan has to pre-approve 
CTA (71275).  
 
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: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has prior neck surgery with 
radiating pain. MRI of the cervical spine is indicated due to the documented symptoms and prior radiographic 
findings consistent. The MRI is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the cervical spine.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device (CPT Code C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not necessary. 
 
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 the device. 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CardioMEMS device (CPT Code C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Librecontinuous glucose monitor.You asked the Plan to pre-approveFreestyle Libre continuous glucose monitor. 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 device.The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered for certain indications.We looked at the file and Medicare rules. Review of the file does not support that the enrollee is insulin treated with three or more daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14060) provided on October 3, 
2019. 
 
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14060 is adjacent tissue transfer or rearrangement, 
eyelids, nose, ears and/or lips; defect 10 sq cm or less. 
 
We asked our coder 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 adjacent tissue transfer. Our reviewer says that CPT code 
14060 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report documents extensive undermining and does not support adjacent tissue transfer. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the adjacent tissue transfer have not been met. Therefore, we decided that the 
Plan does not have to pay for the adjacent tissue transfer (14060) provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Insulinx blood glucose monitor. 
 
You asked the Plan to pre-approve the Insulinx blood glucose monitor. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
received does not indicate that preferred alternative One-Touch test strips, could not be used. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
 
 
 
 
 
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 Insulinx blood glucose monitor. Our 
reviewer says that medical necessity criteria for the requested blood glucose monitor has not been met. Our 
physician reviewer found the documentation submitted does not indicate a reason why the member cannot use 
the Plan's preferred brand. 
 
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 Insulinx blood glucose monitor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Insulinx blood glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have medical conditions that require a physician evaluation at least 3 times per week. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for weakness and a urinary tract infection. Her medical 
problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a 
need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation 
therapy program. 
 
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 waive the copayment for a specialist office visit provided by a 
participating provider on March 16, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were sent to the 
wrong kind of doctor. You say that you do not feel like you should have to pay for this office visit. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
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 $40 
copayment for physician/practitioner services/in-network/provider services/specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. Since specialist services were 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/in-network/provider services/specialist 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 a specialist office visit provided by a participating provider on March 
16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve the attendant control. You say that you would like reconsideration because 
the member does not have motor skills and cannot steer herself. The Plan denied your request. The Plan says 
the requested attendant control cannot be covered in addition to a beneficiary-operated controller Medicare 
rules. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is covered in place of a 
beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable 
to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but 
is able to operate a power wheelchair. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the attendant control have not been met. Specifically, the record indicates that the member can 
operate hand controls for a motorized wheelchair. Therefore, we decided that the Plan does not have to pre-
approve an attendant control (E2331).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Laroia for a vulvectomy (a procedure to remove the 
vulva) (CPT Code 56620). 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The received documentation does 
not indicate that surgery is being done to treat a cancerous or precancerous condition. Therefore, this surgery is 
considered cosmetic. Therefore, we decided that the Plan does not have to pre-approve Laroia for a vulvectomy 
(a procedure to remove the vulva) (CPT Code 56620).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levalbuterol Tartrate HFA 45MCG (CPT Code J3535). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this drug is not covered for the member's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Levalbuterol Tartrate HFA 
45MCG (CPT Code J3535).  
 
Benefits for the medication 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 pay for continuous glucose monitor supplies (K0553) provided on 
June 9, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies.. You say that you would like 
reconsideration because these supplies are medically necessary and will help the beneficiary to better monitor 
and comply with insulin use. The Plan denied your request. The Plan says the medical records provided do not 
indicate that the ordering physician discussed the ordering of a glucose monitor with the member. 
 
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 does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the record does not indicate that the provider discussed the need for a continuous 
glucose monitor for this member. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for continuous 
glucose monitor supplies (K0553) provided on June 9, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285). 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because this service was coded applying industry recognized emergency medical coding standards.  The Plan 
denied your request. The Plan says the documentation does not support CPT code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
 
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 emergency department visit. Our 
reviewer says that based on the emergency department course, this member encounter does not appear to 
qualify for a 99285 code. Our physician reviewer found there was no high severity and immediate threat to life, 
complex history or high level decision making as required. The 99284 would be more appropriate.  
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285)..
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for aquatic therapy provided on November 4, 2019. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved, so you provided 10 
visits. You say that the claims should be processed for payment.  The Plan denied your request. The Plan says 
the services are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 

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 aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had extensive therapy for this condition and the 
documentation notes minimal change in function from prior therapy. Our reviewer says that unique skills of a 
professional therapist were not required to safely and effectively provide 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 aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided on November 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on June 15, 2020, through July 14, 
2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because these 
services are covered under Medicare. The Plan denied your request. The Plan says medical necessity cannot be 
established for the continued stay at the skilled nursing 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found This beneficiary did not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided on June 15, 2020, through July 14, 2020.