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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollees nursing medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted to the hospital on October 22, 2022, for acute respiratory failure, sepsis, aspiration pneumonia, and acute renal failure. He was admitted to the 
intensive care unit for 3 days and required mechanical ventilation. As of November 2, 2022, the enrollee was 
not complaining of shortness of breath and did not require supplemental oxygen. He does not require the 
intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. He does not 
require rehabilitation nursing for complex wound care, tracheostomy management or bowel and bladder 
management. His medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. As of October 31, 2022, the enrollee was requiring contact guard assistance 
for transfers and ambulating 70 feet. He required stand by assistance for dressing. The enrollee has had a 
functional decline from his baseline level of function, but he does not require the intensity of therapies 
provided on acute inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 9, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 3, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says despite multiple outreaches by the Health Plan, this provider has not 
submitted any clinical records to support the medical necessity of the service(s). 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the non-emergency ambulance 
transportation and ground mileage have been met. Medical records were not provided with this case. The 
record shows that the Plan made multiple attempts to obtain this information, but it was not provided. Without 
medical records we are unable to determine if the transportation was medically necessary. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring (code 33289). 
 
You asked the Plan to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring. You say that transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring is medically necessary. The Plan denied your request. 
The Plan says transcatheter implantation of wireless pulmonary artery pressure sensor for long-term 
hemodynamic monitoring 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 transcatheter implantation of wireless 
pulmonary artery pressure sensor for long-term hemodynamic monitoring. Our reviewer says that transcatheter 
implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring is not 
considered medically reasonable and necessary. Our physician reviewer found that the CardioMEMS device 
was approved by the FDA in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope (1). Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device (2). In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor for long-term 
hemodynamic monitoring (code 33289).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 27, 
2022, to January 31, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the request for anticipated payment (RAP) claim for services for dates of service January 27, 2022, to 
January 31, 2022, until January 27, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAS must submit an NOA to their 
Medicare contractor within 5 calendar days after the start of care date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the NOA was 
not submitted within 5 calendar days from the start of care date. Therefore, we decided that the Plan does not 
have to pay for the home health care services provided from January 27, 2022, to January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 9, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not want to be transported because it was during the pandemic, and you did not want to risk being exposed to 
COVID-19. The Plan denied your request. The Plan says the ambulance was called but you were not 
transported to an emergency facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 9, 2022.
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 this would help the enrollee regain her maximum 
function, their medical management and rehab needs require a IRF and close physical supervision. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at a Skilled Nursing Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 hip fracture repair does not require intensive rehabilitation to regain function. The 
enrollee does not require frequent physiatry oversight. Her response to therapy indicates she is not able to 
participate or benefit from intensive. She is receiving appropriate rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and potential for functional improvement however, the documentation doesn't support that she would 
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services fifteen hours a week, 
under the supervision of a physician at least 3 visits weekly to regain or maintain her functional status. The 
enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 needs to be nutritionally 
optimized so they can swallow safely. Enrollee is not appropriate for surgery at this time. The Plan denied your 
request. The Plan says the criteria for admission to the LTACH have not been met. The enrollee's medical 
needs are being met in the current acute setting. The LTACH would add no additional services. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer without permanent feeding source and as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is recommended.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 you do not have complex nursing or rehabilitation needs. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 14, 2022, to June 12, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that at the time of admission, the enrollee required skilled rehab services to improve 
function due to weakness and deconditioning. There were no skilled nursing needs. As of 5/14/2022 the 
enrollee did not require any skilled nursing or rehab services on a daily basis. She was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care as of 5/14/2022. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from May 14, 2022, to June 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport provided on January 18, 
2022. 
 
You asked the Plan to pay for the non-emergency ambulance transport.. You say that this transport was 
medically necessary and you have provided medical records to support payment. The Plan denied your request. 
The Plan says this transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport.. 
Our reviewer says that this transport was not medically necessary. Our physician reviewer found the 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. 
 
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 non-emergency ambulance transport. have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transport provided on January 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging, spinal canal and 
contents, lumbar; without contrast material to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a magnetic resonance imaging, spinal canal and contents, lumbar; without 
contrast material to be provided by an out-of-network provider. The Plan denied your request. The Plan says 
this service is available within the health Plan network. Out-of-network care is only covered if this is a medical 
emergency and there are no network providers available. We do not see that this is emergency medical care. 
We know that there are network providers who can give this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material to be provided by an 
out-of-network 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 can tolerate multiple therapies and are willing 
and able to participate in multiple therapies. You say you are getting weaker. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility (SNF). 
 
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 to the hospital with increased confusion. You were diagnosed and 
treated for bacteremia with a urinary tract infection and a pleural effusion. The record showed you improved. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab 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, at 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.