Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measurement of vitamin D 25 hydroxy (82306) provided 
on August 17, 2022. 
 
You asked the Plan to pay for the measurement of vitamin D 25 hydroxy. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not covered for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the measurement of vitamin D 25 hydroxy, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the measurement of vitamin D 25 hydroxy (82306) provided on August 17, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 is medically stable and does not need PM&R 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. At the current high functional level, the enrollee does not need 3 hours a day x 5 
days a week of therapies with multidisciplinary approach in an IRF. Document does not support medical 
necessity for admission to an IRF. The enrollee has no current medical complexity or rehab nursing needs other 
than routine nursing care. The enrollee's rehab needs can be safely met in an alternate and low intensity setting 
such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) billed for date of service April 22, 2022. 
 
You asked the Plan to pay for a TENS device. You say that the item at issue was 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 there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a TENS device (E0730) billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing billed with code 0037U provided on June 
9, 2022. 
 
You asked the Plan to pay for code 0037U. You say that the testing was medically necessary. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 0037U have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory testing billed with code 
0037U provided on June 9, 2022.
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 the enrollee is in a lot of pain and needs rehab so that 
they can strengthen their neck. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can receive the care they need in another setting. 
 
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 require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
 
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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided November 27, 2021, to 
December 1, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an admission was medically 
necessary. The Plan denied your request. The Plan says that an admission 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 based on the progression of her recovery following the surgery, it was expected that the patient 
would require hospital services that would likely cross 2 midnights for monitoring and treatment. 
 
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 the acute inpatient hospital care provided November 27, 2021, to December 1, 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: 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 IRF care. The Plan denied your 
request. The Plan says the records do not show the need for the intensity of an IRF or full-time access to a 
doctor or skilled rehabilitation nurse. Needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for partial hospitalization therapeutic items and services provided from 
March 4, 2022, to March 15, 2022. 
 
You asked the Plan to pay for therapeutic items and services. You say that your doctors wanted you to stay in 
the hospital to rehabilitate. The Plan denied your request. The Plan says that the denial of payment for these 
services is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for these services, but did not provide any rationale or 
evidence to support a denial. You say that you needed to remain in the hospital following surgery for 
rehabilitation. The Plan has not shown that its decision to deny payment for these items and services is correct 
or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for partial 
hospitalization therapeutic items and services provided from March 4, 2022, to March 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment received on June 1, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the items received are not a covered benefit when received by a 
provider that is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen equipment received on June 
1, 2022.
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 you are appealing the denial with clinical 
documentation to support this request. The Plan denied your request. The Plan says that the admission to a 
LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to still be unstable on high flow oxygen but is improving 
and should only require short-term additional acute care hospital services that can safely be provided at the 
current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the transfer bench (E0248), raised toilet seat 
(E0244), bath tub wall rail (E0241), and the walker tray (E1399) provided from May 18, 2022, through  
June 23, 2022.  
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered 
benefit by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are considered hygienic equipment that is not primarily medical in nature. The rules also 
say that grab bars are not covered because they are considered self-help items that are not primarily medical in 
nature.   
 
While the items provided may be appropriate in this case, neither the Plan nor Medicare offers coverage for 
these items. Therefore, we decided that the Plan does not have to issue reimbursement for the transfer bench 
(E0248), raised toilet seat (E0244), bath tub wall rail (E0241), and the walker tray (E1399) provided from  
May 18, 2022, through June 23, 2022.
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 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 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 acute hospital can provide for all the enrollees present inpatient care needs and 
the patient is receiving an appropriate level of care in the present setting. The provided records do not explain 
what care services will be provided in the LTACH that are not available in the present hospital 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: 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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 the enrollee is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation.  The enrollees care needs can be met 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 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. You say that the enrollee is in no condition to be released home 
and needs rehabilitation to regain his strength. 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for urinary tract infection and dehydration. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to April 
13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography (CT) (76377), transthoracic echocardiography (TTE) (93306), and myocardial straining 
causing speckle tracking-derived assessment of myocardial mechanics (93356) provided on July 18, 2022. 
 
You asked the Plan to pay for the diagnostic services. You say that the services were medically necessary. You 
also say that this should be reprocessed and paid. The Plan denied your request. The Plan says the services 
were 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 pay for the diagnostic services. Our reviewer says 
that the requested diagnostic services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found clinical guidelines do not support that a TTE be performed in the setting indicated on the claim. Therefore, the reviewer found there is no evidence to support the medical necessity of the service in 
this case. 
 
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 diagnostic services have not been met. Therefore, we decided that the Plan 
does not have to pay for the 3D rendering with interpretation and reporting of computed tomography (CT) 
(76377), transthoracic echocardiography (TTE) (93306), and myocardial straining causing speckle tracking-
derived assessment of myocardial mechanics (93356) provided on July 18, 2022.