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 are very weak and need to regain your strength 
and cognitive abilities. The Plan denied your request. The Plan says 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for cardiac surgery complicated by renal and respiratory failure. Your medical problems are stable, and you have 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical 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. 
 
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 pay for code 99424 provided on June 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for code 99424. You say that your company has an exclusive contract with the 
facility where the patient was located, so this service should be covered. The Plan denied your request. The 
Plan says unauthorized, out-of-network services are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for code 99424 provided on June 2, 2022, by an out-of-network 
(OON) provider.
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 are not able to perform your activities of daily 
living and need more physical therapy. The Plan denied your request. The Plan says IRF care 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
total knee replacement and were discharged home on October 19, 2022. Your medical problems are stable, and 
you have no complex nursing or rehabilitation needs.  You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical 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. 
 
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 pre-approve an office visit for a second opinion, to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are requesting an out of network second 
opinion to confirm your father's diagnosis. The Plan denied your request. The Plan says the enrollee must use 
in network providers to receive services. There is appropriate care available with the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit for a second opinion, to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) and DME delivery, set up, and/or 
dispensing service component of another (A9901) provided on April 4, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the orthosis. You say that after therapy you were asked if you wanted a knee 
brace. The therapist said it would be covered by the Plan. He did not state that you would need approval from 
your knee doctor. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and DME delivery, set 
up, and/or dispensing service component of another (A9901) provided on April 4, 2022 by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve skilled nursing facility services. You say that you are requesting 
reconsideration of approval for SNF services at the requested location. The Plan denied your request. The Plan 
says based on Medicare guidelines, your request for an SNF admission in an out-of-network facility does not 
meet the requirements for approval. The Plan also says that you have been previously approved for SNF 
admission at an in-network facility, which is 22 miles from the location you had requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device coded as 
22869 and 22870. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this treatment is considered safe and 
effective, as supported by its clinical benefits to patients, continued medical professional adoption, and strong 
clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says this 
device experimental and investigation. Medical studies have not proven this service is helpful for the treatment 
of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous device coded as 22869 and 22870.
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 waiting to be transferred from the hospital 
and you cannot care for yourself at home. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 you were admitted for surgical repair of a hip fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 IRF admission and services.
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 was admitted for a stroke 
and now requires LTACH level of care to fully recover. The Plan denied your request. The Plan says this is not 
medically necessary and continued acute hospital care was offered until enrollee could discharge to a lower 
level of 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. Our 
physician reviewer found 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from December 2, 
2021, to December 4, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. The enrollee presented with complaints of head, neck, left 
hip, and low back pain, and was evaluated with a history and physical exam, laboratory studies, and computed 
tomography (CT) scans of the head, cervical spine, and pelvis. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from December 2, 2021, to December 4, 
2021.  
 
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 bioimpedance spectroscopy (BIS) assessment using 
Impedimed L-dex testing device (93702). 
 
You asked the Plan to pre-approve the Impedimed L-dex testing device. You say that based on the evidence 
above and what you believe to be proven medical necessity, you are asking for authorization of this procedure 
for the enrollee. The Plan denied your request. The Plan says there are not enough studies on Bioimpedance 
spectroscopy to show that it is safe and effective to diagnosed lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Impedimed L-dex testing device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bioimpedance spectroscopy (BIS) assessment using Impedimed L-dex testing device 
(93702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar artificial disc replacement surgery coded as 
22857 and 0163T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that given the enrollee's medical history and 
the indication for prodisc L2 levels, you are confident that the Plan will agree that the prodisc L2 levels is 
medically necessary for the enrollee. The Plan denied your request. The Plan says this procedure is covered for 
people 60 years of age and over. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. CMS has found that LADR is not reasonable and necessary for the 
Medicare population over 60 years of age; therefore, LADR is non-covered for Medicare beneficiaries over 60 
years of age. In this case, the enrollee is 68 years old. Based on this information, we decided that Medicare 
rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar artificial disc replacement surgery coded as 22857 and 0163T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of Vertiflex interspinous and interlaminar 
spacer device coded as 22869 and 22870. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the records provided support the necessity 
of the requested service. The Plan denied your request. The Plan says this procedure is considered experimental 
and investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the insertion of Vertiflex interspinous and interlaminar spacer device coded as 22869 and 22870.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this member is currently receiving care 
at a short term acute care hospital (STAC) and is under your care. You also say that the member currently 
meets LTACH admission criteria under the Centers of Medicare and Medicaid Services (CMS) guidelines. The 
Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services being requested do 
not meet the requirements for approval. 
 
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 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. Our physician reviewer also found that the Plan 
has approved ongoing care in the current acute care 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(CPT code E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that the bed is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 hospital bed have not been met. You do not weigh more than 
350 pounds. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the 
beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 
350 pounds, but does not exceed 600 pounds. Therefore, we decided that the Plan does not have to pre-approve 
the hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 
600 pounds, with any type side rails, with mattress (CPT code E0303).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemcitabine Hcl, Carboplatin, Granisetron, 
Ondansetron, and Dexamethasone. 
 
You asked the Plan to pre-approve Gemcitabine Hcl, Carboplatin, Granisetron, Ondansetron, and 
Dexamethasone. 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gemcitabine Hcl, Carboplatin, 
Granisetron, Ondansetron, and Dexamethasone. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the regimen is not standard for intrahepatic biliary cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine Hcl, Carboplatin, Granisetron, Ondansetron, and Dexamethasone 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine Hcl, 
Carboplatin, Granisetron, Ondansetron, and Dexamethasone.