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

 
We decided that the Plan has to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 inpatient psychiatric admission. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found based upon review of the records provided, this enrollee does meet the criteria 
for treatment in an acute inpatient mental health treatment beyond the date in question of December 4, 2020 
forward. Although the enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, or delusions the enrollee was showing behaviors and aggression with acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric admission have been met. Therefore, we decided that the 
Plan has to pre-approve inpatient psychiatric 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that a spinal cord stimulator trial is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for coverage of a spinal cord stimulator trial. 
The Plan follows Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include psychological evaluation. 
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 spinal cord stimulator trial. Our 
reviewer says that a spinal cord stimulator trial is not medically necessary at this time. Our physician reviewer 
found the patient does not have an evidence-based indication for a spinal cord stimulator trial. The request is 
not medically reasonable or 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted for thoracolumbar spinal surgery. The enrollee's medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The documentation does not support that the enrollee requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
the enrollee requires 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the complex repair (13121) provided on April 20, 2020. 
 
You asked the Plan to pay for the complex repair. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for 
revision/closure of complication of arteriovenous anastomosis. 
 
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 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm 
to 7.5 cm. 
 
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 complex repair. Our reviewer says that CPT code 13121 
does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 13121 would not be 
reported for revision/repair of arteriovenous fistula.  There is a more appropriate code for this procedure.  It is 
inappropriate to report Modifier 78, as CPT 13121 is not a related procedure for revision/repair arteriovenous 
fistula. 
 
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 complex repair have not been met. Therefore, we decided that the Plan does 
not have to pay for the complex repair (13121) provided on April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 18, 
2020, through July 21, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you weren't informed that all 
hospital expenses wouldn't be paid. You say that you will have a problem paying this amount. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
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 $355 per 
day, days 1-5 and $0 per day, days 6-90. Cost-sharing is charged for each in-network, medically necessary 
covered inpatient stay.  
 
You have been asked to pay $1,065 copayment for the inpatient stay. ($355/day x 3 days = $1,065). The 
inpatient 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 the inpatient stay provided from July 18, 2020, through July 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee's needs could be met 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found while there are identifiable skilled nursing 
service needs, the beneficiary does not require skilled nursing or therapy services on a daily basis. The 
beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an 
LTACH in order to regain maximum and prior levels of functioning. You say that LTACH care is needed to 
continue a multi-disciplinary approach to care and that LTACH care is needed instead of short term acute care 
as the enrollee is expected to require another 3-4 weeks to transition from acute illness. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs 
can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital for exploratory 
laparotomy and subtotal colectomy and new ileostomy for pneumoperitoneum with bowel perforation related to 
ulcerative colitis. The course was complicated by delirium, acute respiratory distress, and pulmonary edema, 
requiring thoracentesis. He was also treated for DVT status post IVC filter placement, sacral ulcer, and intra-
abdominal abscess requiring drainage. Most recently his renal function has declined and he was diagnosed with 
GI bleed requiring blood transfusion. He is being considered for dialysis at this time. He was able to be weaned 
from ventilation support since and does not require oxygen. The enrollee appears to have been gradually 
improving but has experienced a worsening of kidney function and GI bleed which requires additional short 
term acute care services which can be safely be completed in the current setting. The enrollee 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 enrollee requires that are not already available and covered at the current facility. Therefore, this 
request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level 
of care may be considered when treatment has completed and the enrollee is more stable. 
 
 
 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost for the office visit, betamethasone acetate injection and wrist 
brace provided on August 6, 2020. 
 
You asked the Plan to waive the cost for the office visit, betamethasone acetate injection and wrist brace. You 
say that additional expenses should not be passed onto you. You say that insurance should pay the full amount. 
The Plan denied your request. The Plan says that the cost share applied correctly. 
 
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 did not submit the Evidence of Coverage. This means that we cannot 
determine that the cost you are being asked to pay is correct or justified by the Plan contract. Therefore, we 
decided that the Plan has to waive the cost for the office visit, betamethasone acetate injection and wrist brace 
provided on August 6, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
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 improving overall, however, they require additional short 
term acute care services which can safely be completed in the current setting. 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. Therefore, this request 
for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care 
may be considered soon when treatment has completed. 
 
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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet Step Therapy criteria for coverage of Procrit. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically necessary at this time. Our physician reviewer found there is not sufficient evidence in the 
medical records to support the use of Procrit versus other Epoetin formulations that are available. The enrollee 
can attain increased erythropoietin levels with Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
December 19, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that it is felt that continued care is needed. 
The Plan denied your request. The Plan says the care required is now mainly custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a female with 
chronic kidney disease, hypoglycemia, and muscle weakness. From a nursing perspective, the beneficiary 
received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the 
beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a minimal assist to 
maxima assist level with functional mobility. The beneficiary required varying assist with ADLs. 
 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes 
L8040, L8041, L80423 on July 9, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service. 
 
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 a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, the billed code cannot be verified.  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 the 
durable medical equipment (DME) as defined by codes L8040, L8041, L80423 on July 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care from December 22, 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 identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care from December 22, 2020, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance cholangiopancreatography (MRCP) 
(CPT Code S8037). 
 
You asked the Plan to pay for the service. You say that the service was recommended for further evaluation 
and that this could be used to help evaluate the bladder as well. The Plan denied your request. The Plan says 
they did not make a timely decision. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Medicare guidance says status code Not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Therefore, we decided that the Plan does not have to pay for 
magnetic resonance cholangiopancreatography (MRCP) (CPT Code S8037).