Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
has COPD and chronic productive cough. The enrollee has been using a flutter valve and Mucinex without 
relief. A chest x-ray report from February 3, 2023, describes "Right perihilar and infrahilar bronchiectasis...". 
However, there is no chest computed tomography (CT) scan to confirm the bronchiectasis. There is no 
diagnosis of cystic fibrosis or neuromuscular disease. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot take care of your basic needs and are not 
physically able to take care of yourself. The Plan denied your request. The Plan says the requested IRF 
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 in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket. 
 
You asked the Plan to pre-approve the socket. You say that the enrollee has a history of skin irritation on his 
residual limb. The Plan denied your request. The Plan says the item is not shown to be safe and effective. 
 
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 socket. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there are no extenuating circumstances on a physician progress note that require the 
L5781. The literature reviewed indicates that further research is needed with clinical trials that recruit larger 
sample sizes and report long-term outcome data for the requested vacuum suspension system. 
 
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 socket have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum socket.
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 enrollee will require an LTACH level 
of care and is currently stable for discharge. The Plan denied your request. The Plan says the records do not 
show that it is medically necessary to be in an LTACH. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
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 SSBCI benefits. Our reviewer says that 
the requested SSBCI benefits are not medically reasonable and necessary. Our physician reviewer found that 
the enrollee is a 57-year-old female with a history of HTN, GERD, obesity status post gastric sleeve, allergies, 
anemia, Graves disease status post radioactive iodine ablation, and vitamin D deficiency. There is no 
documentation provided indicating that the enrollee meets the criteria for coverage of the requested SSBCI 
benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
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. The Plan denied your request. The Plan says the enrollee doesn't meet all the requirements for inpatient rehabilitation, medically necessary care may be provided safely in 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a static progressive stretch device. 
 
You asked the Plan to pre-approve the device. You say that the enrollee is expected to restore range of motion 
with the device. The Plan denied your request. The Plan says experimental services are not covered. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the literature does not support that this specific device is effective in patients with chronic knee 
stiffness. The patient is over one year post knee surgery. Per the literature a standardized protocol of use for 
SPS (static progressive stretch) knee braces has not been reported.  
 The literature indicates identifying patient need within the first 12 weeks (i.e., those with stiffness) instead of 
those with chronic contractures (more than six months) can yield enhanced outcomes. The SPS device should 
be considered prior to any surgical procedure. The literature also indicates that further research using 
randomized controlled trial designs is required to investigate efficacy of home medical stretching devices and 
longer term follow up of patients in the treatment of arthrofibrosis following total knee replacement (TKR).  
 
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 a static progressive stretch device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 16, 2022, to 
October 5, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this claim is missing the visit with the appropriate G- codes for the billed 
dates of service.  
The Plan must follow Medicare rules. Medicare rules say that home health visits must be billed with the 
appropriate G- code to represent the services performed.  
 
We looked at the file and Medicare rules. This claim does not include the appropriate G- codes for the billed 
dates of service. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided from September 16, 2022, to October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If the enrollee does have severe chronic obstructive pulmonary disease (COPD) with chronic carbon 
dioxide (CO2) retention, they may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional units of neuropsychological testing. 
 
You asked the Plan to pre-approve the additional testing. The Plan denied your request. The Plan says the 
additional testing is not medically 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 additional testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had previously been approved for neuropsychological testing. The 
requested neuropsychological testing is not considered to be reasonable or medically necessary as it is 
considered to be excessive. 
 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 additional testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 additional units of neuropsychological testing.
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 enrollee is unsafe to discharge to 
home at this as they require intensive rehabilitation because of their condition. You also say the enrollee's 
provider does not believe their care needs can be adequately met at a lower level of care. The Plan denied your 
request. The Plan says the requested LTACH services are 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 that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 for 
November 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
billed with code G2067 for November 14, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on October 23, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you timely filed this claim, so it 
should be paid. The Plan denied your request. The Plan has not provided any denial rationale in the limited case 
file it sent to us. 
 
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. Specifically, the Plan has failed to explain why this claim was denied.  The Plan 
failed to provide us with copies of any denial notices or any documentation that would have laid forth an 
argument for non-coverage of this claim.  The burden is on the Plan to show why its denial was appropriate.  
By failing to provide any of this information, we find that the Plan has not met this burden. Therefore, we 
decided that the Plan has to pay for physical therapy services provided on October 23, 2019.  
 
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 enrollee meets criteria for medical 
complexity requiring physician oversight as well as skilled therapy. The Plan denied your request. The Plan 
says the requested LTACH admission 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 documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH. The requested treatments are not medically necessary at the LTACH level of care.  The 
member has improved medically and can receive further care at the current acute care hospital or a lower level of care when deemed 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.