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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 was admitted to the hospital for weakness and a fall and was transferred 
to a skilled nursing facility (SNF) on November 23, 2022. He is now medically stable with no complex nursing 
or rehabilitation needs. He does 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. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Voriconazole. 
 
You asked the Plan to pre-approve Voriconazole. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Voriconazole.  
 
Benefits for Voriconazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service November 
16, 2021, to November 22, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service November 16, 2021, to November 22, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says you do not need three hours a day of therapy. The Plan says that 
your medical illnesses are stable and that you do not need a rehabilitation physician to monitor you three times 
a week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
syncope and non-surgical management of a skull fracture and odontoid fracture after a fall.  Your medical 
problems are stable. There are 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. 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be optimally restored 
at any other level of care. You say that the medical records provided support the need for LTACH care. The 
Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital and go to an LTACH. 
The Plan says that the enrollee is receiving the care needed in the hospital where they are now, and there is no 
need for transfer. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. 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 health plan. The health 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving the enrollee a 
"referral." 
 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 office visit provided on May 17, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehab to become more 
independent. You say that you need intensive therapy with medical oversight. The Plan denied your request. 
The Plan says the IRF 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. You say that the medical records provided 
confirm the medical necessity of the requested services. The Plan denied your request. The Plan says the 
requested treatment is not appropriate for treatment of discomfort in both legs with walking. The Plan says that, 
although there may be narrowing the artery, three is no evidence that treating it will improve the enrollee's 
outcome. The Plan says that there is no evidence that the enrollee has been in a supervised exercise program or 
equivalent. The Plan says that there is no evidence that the enrollee has tried Pletal. 
 
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 revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the medical necessity 
of the treatments in question.  It appears that the provider is considering peroneal artery endovascular 
intervention for the treatment of claudication.  There is no suggestion of arterial disease proximal to this in the 
left lower extremity.  The description of the patients walking symptoms is not well documented.  It is very rare for a patient to have claudication due to isolated tibial disease.  Additionally, as peroneal artery endovascular 
intervention has a high risk of recurrence and potential to worsen the natural history of the disease by 
intervention it is usually reserved for cases concerning for limb threat.  The documentation does not provide 
sufficient support for this procedure to the degree that it can be considered 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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
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 requested admission to an IRF 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 documentation shows that the enrollee has functional impairments but there are no 
complex deficits specified. Additionally, the enrollee does not meet IRF compliant criteria after total knee 
arthroplasty. There are no active medical comorbidities thus the complexity of the enrollee's nursing, medical 
and rehabilitation needs do 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: 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 the enrollee needs to be monitored for pain 
management and the enrollee would not be safe at home. The Plan denied your request. The Plan says the 
Medicare guidelines for IRF services were not met and the services the enrollee needs can be provided 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 that the clinical documentation shows that the enrollee has complex functional 
impairments (as hip fracture is IRF compliant). However, there are no documented active medical 
comorbidities thus the enrollee would not be expected to require inpatient hospitalization for close medical 
monitoring during rehabilitation. The complexity of the enrollee's nursing, medical and rehabilitation needs do 
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 IRF admission and 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 the enrollee meets the criteria for an IRF stay. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for IRF admission, 
and the enrollee can receive the care that they need at a lower level of care like at 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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no nursing needs documented. At 
the current functional level, the enrollee does not need 3 hours a day at 5 days a week of therapies with 
multidisciplinary approach in an IRF. 
 
The documentation does not support medical necessity for admission to an IRF. The enrollee has no medical 
complexity, and no rehabilitation nursing needs other than routine nursing care. While the enrollee may benefit 
from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely met in an 
alternate and low intensity setting such as in a SNF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duet rollator/transport chair, 8" casters. 
 
You asked the Plan to pre-approve a duet rollator/transport chair, 8" casters. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item 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 a duet rollator/transport chair, 8" 
casters. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee a medical history of diabetes mellitus type II, 
hypertension, hyperlipidemia, obesity, and lumbar radiculopathy. A clinical progress noted dated September 
23, 2022, indicated that the enrollee had left sided chest wall pain and intercostal neuritis. A clinical progress 
note dated September 9, 2022 indicated that the enrollee had an antalgic gait with normal motor strength in the 
upper and lower extremities. The documentation provided does not support the need for the duet 
rollator/transport chair. The enrollees level of mobility is unclear, and the enrollee is noted to have normal 
motor strength in the upper and lower extremities. It is not clear why the enrollee cannot use a standard walker 
to help with mobility. Therefore, the enrollee does not meet criteria for the requested item. 
 
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 duet rollator/transport chair, 8" casters have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a duet rollator/transport chair, 8" casters.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2021, to 
October 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 
(Sepsis, unspecified organism) is a valid diagnosis for this encounter. The Plan denied your request. The Plan 
says the billed secondary diagnosis of A41.9 (Sepsis, unspecified organism) is not supported in the medical 
record, resulting in a lower DRG being paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code A41.9 (Sepsis, 
unspecified organism). 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the billed secondary diagnosis of A41.9 (Sepsis, 
unspecified organism) is not supported in the medical record. Our physician reviewer found the enrollee was 
admitted for an elective transurethral resection of the prostate (TURP). Post-operatively he developed an 
elevated white blood count of 19T. His vital signs were stable; chest x-ray was negative and lab results were 
suggestive of a urinary tract infection. The enrollee's urine culture was positive for E coli. He was treated with 
IV fluids and IV antibiotics. His condition stabilized and improved, and he was discharged home on October 
11, 2021. Sepsis is a life-threatening syndrome usually caused by bacterial infection. Sepsis is a response of the 
body's immune system that results in organ dysfunction or failure. The systemic inflammatory response 
syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure Assessment (qSOFA) 
in 2016, allowing for quick bedside analysis of organ dysfunction in patients with suspected or documented 
infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, systolic blood pressure of 
100 mm Hg or less, and altered level of consciousness. For completeness, severe sepsis is defined as sepsis 
complicated by organ dysfunction. In this case, there was no clinical or laboratory evidence of sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 4, 2021, to October 11, 2021, at the Diagnosis Related 
Group (DRG) originally billed.