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 require additional care to regain your strength 
and mobility. The Plan denied your request. The Plan says your records do not show that you need to be seen 
by a rehabilitation doctor three times per week, or that you need an intensive team for your rehabilitation. 
 
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 lower extremity cellulitis. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the enrollee continues to complain about pain in her 
knees. The Plan denied your request. The Plan says the enrollee has not tried and failed any of the preferred 
agents. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our physician reviewer 
found that the enrollee has osteoarthritis of the knees. The Plan requires a trial of Orthovisc, Synvisc, or 
Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
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 does meet LTAC admission 
criteria and the ongoing medical care warrants an LTAC level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for transfer to a 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 the requested LTACH services are not medically necessary, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where they are currently receiving 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 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: 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 enrollee needs inpatient rehabilitation following 
treatment and debridement of left leg ulcer with skin grafts and application of wound vac. Inpatient 
rehabilitation is necessary for wound management and for the enrollee to regain maximal physical function. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee they don't meet 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 was admitted for cellulitis of the lower limb and was discharged home on 
7/10/2022. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an inpatient 
rehabilitation program 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 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. Our reviewer also found that 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 you are pursuing an expedited appeal to 
support LTACH placement. The Plan denied your request. The Plan says according to the information 
reviewed on the appeal, the requested service is not 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 enrollee was admitted to the acute care hospital with an infected wound following 
gastric bypass surgery. Recent notes describe the enrollee as responding to current treatment and is reported to 
be awaiting skilled nursing facility placement. The enrollee is receiving appropriate care at the present setting. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 12, 
2021. 
 
You asked the Plan to pay for procedure code 83789. The Plan denied your request. The Plan says payment for 
code 83789 is bundled into payment for code 80307.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83789 
is a column II code to column I code 80307. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 83789 billed for date of 
service March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 25, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81479 is the only covered code for 
Guardant360 testing.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per LCA A58192, this testing is only covered when billed with code 81479. Based on this information, 
we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant360 testing provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar/sacral transforaminal epidural injection with 
imaging guidance (64483). 
 
You asked the Plan to pre-approve the spinal injection. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the injections is not medically 
necessary as the pain relief or improved function did not last for at least 3 months. 
 
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 spinal injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has low back pain, with pain that radiates bilaterally to her anterior 
thighs and shins. The pain affects her daily activities and quality of life. A bilateral L4 ESI was done on 
04/29/22 with Lidocaine and Dexamethasone. She had 100% improvement in her pain that lasted 2 days and 
then 50% improvement in her function that lasted six weeks. She has completed home exercise program (HEP) 
and is to start outpatient physical therapy. The LCD requires 3 months of pain relief, not just 6 weeks. 
Therefore, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the spinal injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the lumbar/sacral transforaminal epidural injection with imaging guidance (64483).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation services. 
 
You asked the Plan to pre-approve non-emergent ambulance services. You say that the enrollee has exhausted 
other transportation methods and requires transportation to get to a temporary dialysis center. The Plan denied 
your request. The Plan says the criteria for non-emergent ambulance transportation are not met in this case. 
There is no documentation to show that the enrollee cannot be transported in another vehicle. 
 
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 pre-approve non-emergent ambulance services. Our 
reviewer says that Medicare criteria for coverage of non-emergent ambulance services are not met in this case. 
Our physician reviewer found at the time of this request, the enrollee was at baseline with stable vitals and did 
not require any treatment during transport. The documentation does not support that means of transport (such 
as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for this enrollee. 
The documentation does not support that the enrollee needs the expertise, services and life-saving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport, and therefore the 
requested transport is not medically reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergent ambulance transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism, electric, any type (E0627) and 
miscellaneous DME supply, accessory, and/or service component (A9900). 
 
You asked the Plan to pre-approve a power seat lift chair. You say that the reason for the appeal listed in the 
denial letter for no assessment is incorrect. The assessment has been completed and the Plan just needs to 
revisit the issue. The Plan denied your request. The Plan says the records do not support that the enrollee meets 
the medically necessary criteria for the requested power seat lift chair. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 power seat lift chair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal objective evidence of a severe hip or knee arthritis. The documentation indicates the enrollee has a history of rheumatoid myopathy, however the 3/7/22 
progress note indicates normal upper and lower extremity motor strength and there is no evidence from the 
most recent progress note of history and physical exam findings suggesting a current rheumatoid myopathy.   A 
seat lift is included in the treating practitioner's course of treatment as an addendum but notes the patient needs 
this for "morbid obesity and other comorbidities." The documentation does not reveal that the enrollee is 
completely incapable of standing from a chair in the home. The enrollee has the ability to ambulate.  The seat 
lift is not likely to (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the 
enrollee's condition.  
 
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 power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism, electric, any type (E0627) and miscellaneous DME supply, 
accessory, and/or service component (A9900).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued inpatient psychiatric services. 
 
You asked the Plan to approve these services. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 approve these services. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 24, 2022 with recurrent episode 
of major depressive disorder, severe without psychotic features, generalized anxiety disorder, and opiate use 
disorder. Based on the submitted records, it is not expected that he will improve in a reasonable period of time, 
as he is not showing dangerousness to self or others, auditory or visual hallucinations, delusions, or behavioral 
issues. He is cooperative and compliant with care. It does not appear that active treatment is taking place. It 
does not appear that the services are reasonably expected to improve his condition or for the purpose of 
diagnosis. The continued inpatient psychiatric services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to approve continued inpatient psychiatric 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 the special supplemental benefits. The Plan denied your request. The Plan 
says this service is not a covered benefit. The Plan also says that the enrollee does not meet the requirements 
for the SSBCI program. 
 The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefits have not been met. Specifically, we have been unable to confirm 
that the enrollee has one of the eligible conditions listed in the Evidence of Coverage. There is insufficient 
evidence showing the enrollee meets the criteria for these benefits. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor (CGM) sensors 
(K0553) provided on October 28, 2021. 
 
You asked the Plan to pay for Freestyle Libre CGM sensors. You say that the item at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the available medical records do not discuss the item at issue. Therefore, we decided 
that the Plan does not have to pay for Freestyle Libre continuous glucose monitor (CGM) sensors (K0553) 
provided on October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the skilled nursing 
facility (SNF) services you are requesting do not meet the requirements for approval. 
 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 pre-approve skilled nursing facility (SNF) services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found after careful 
review, I agree with the denial of skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.