Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) and advance care 
planning (99497) provided on January 8, 2021. 
 
You asked the Plan to pay for the initial nursing facility care and advance care planning. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation does not support the services billed. 
 
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, the CPT Code Manual definition of code 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity.  Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
The CPT Code Manual definition of code 99497 is advance care planning including the explanation and 
discussion of advance directives such as standard forms (with completion of such forms, when performed), by 
the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family 
member(s), and/or surrogate. 
 
We asked our coder 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 initial nursing facility care and advance care planning. 
Our reviewer says that CPT code 99306 does not meet criteria for billing or reimbursement consideration. 
Documentation does not support the 3 key components (Comprehensive history; Comprehensive exam; and 
MDM High complexity) required for this procedure code. Documentation includes a history taken for this date 
of service, therefore this procedure code cannot be verified as performed. 
 Our reviewer found CPT code 99497 does not meet criteria for billing or reimbursement consideration. 
Documentation does not include advance care planning including explanation and discussion. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the initial nursing facility care and advance care planning have not been met. 
Therefore, we decided that the Plan does not have to pay for the initial nursing facility care (99306) and 
advance care planning (99497) provided on January 8, 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 IRF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for IRF care have 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 the enrollee is a 62-year-old man who was admitted to the hospital on February 
13, 2022 after he was struck by a car, suffering a skull fracture and bilateral subarachnoid hemorrhages and a 
subdural hemorrhage. The enrollee has documented impaired cognition, intermittent confusion, and still doesn't 
follow all commands. In this case, the complexity of the patient's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
available documentation does not support that the enrollee requires at least 3 hours a day / 5 days a week, or 15 
hours over 7 consecutive days, of therapy services. In conclusion, it is not clear 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: 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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. You say that the enrollee needs intensive therapy and cannot stand 
on his own. You say that the enrollee is at high risk for falling and his wife cannot take care of him. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says 
that the enrollee can safely receive the services needed in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Available 
records do not document any unstable medical conditions that require a physicians evaluation three or more 
times per week. The enrollee does require physical therapy and occupational therapy services, but the medical 
records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. 
Provided records do not explain why the intensive inpatient rehabilitation therapy program is necessary and 
why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the enrollee. 
There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. Records do not clarify why care at the skilled nursing facility level is not 
appropriate 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 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: Favorable

 
We decided that the Plan has to pre-approve continuation of inpatient mental health care from February 25, 
2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the stay is medically 
necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. The Plan states 
you do not have a plan or intent to harm yourself or anyone else. The Plan states you are not hearing voices 
telling you to harm yourself or others, you are not aggressive or violent, and there are no medical problems 
reported. The Plan states there are no severe side effects from medications, and you could be treated in a lower 
level of care. 
 
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 pre-approve inpatient psychiatric hospital services. 
Our physician reviewer found you do meet the criteria for continued acute inpatient mental health treatment for 
the dates in question of February 24, 2022, forward as although you were shown to be a danger to yourself or 
others and were not showing any auditory or visual hallucinations, you were cooperative/compliant with 
treatment and were responding to 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve continuation of inpatient mental health care from February 25, 2022, forward.  
 
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 pre-approve the MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G Orthotic device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is experimental. 
 
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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term 
use. 
 
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 MyoPro Motion G Orthotic device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
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 is ready for discharge and cannot go 
home by herself. You say that the enrollee needs this care in order to habilitate. You say that the enrollee needs 
extensive care and lives alone. You say that skilled nursing facility therapy is not enough. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely 
receive the services needed in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that the enrollee requires at least 3 hours a day/5 days a week, or 15 hours over 
7 consecutive days, of therapy services but there other indicators that this enrollee requires and can participate 
in a rehabilitation therapy program sufficient for this level of care. The documentation supports that therapy 
services may be provided 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you need this item. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) services. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has shown an increase in dementia 
and Alzheimer's symptoms. You say that the enrollee has a wide gate and is unbalanced while walk. You say 
that testing is needed to further assess the enrollee's needs. The Plan denied your request. The Plan says there is 
not enough evidence showing the requested study would improve the outcome of the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is covered when an enrollee meets 
diagnostic criteria for both AD and FTD. 
 
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 PET scan. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee was seen for a 
neurology evaluation regarding complaints of a memory impairment. She was otherwise noted to have a family 
history of Alzheimer's Dementia (AD.) The records provided for review however did not indicate that there 
was any suspicion for and/or concern for both frontotemporal dementia (FTD) and AD. The requested testing is 
only covered when an enrollee meets diagnostic criteria for both AD and FTD and the enrollee does not meet 
this initial requirement. The requested PET scan would not be reasonable and necessary at this time. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan 
states the enrollee's care can be provided in the current inpatient hospital. 
 
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 with acute hypoxic respiratory failure due to aspiration 
pneumonia in the setting of tracheal stenosis and esophageal cancer. The record indicates that the enrollee is 
improving but requires ongoing acute care services. The enrollee continues to receive acute care services ,and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. The requested service cannot be 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on June 22, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
it is the responsibility of the facility to verify eligibility. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on 
June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
30, 2021. 
 
You asked the Plan to pay for home health services. You say that you have not received any payment. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the file does 
not show that a RAP was submitted within 5 days from the start date. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promacta tablet 75mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit. 
 
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 Promacta tablet 75mg for the enrollee.