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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medical records do not support the need for an intensive 
rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital stay with an interdisciplinary approach to rehabilitation care.  The enrollee does 
have a past medical history of end stage renal disease, diabetes, and neuropathy and is living at home with 
progressive neuropathy.  The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. 
 
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 is not at their baseline, they need 
additional rehab services to be able to safely return home. The Plan denied your request. The Plan says the 
request 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 that the enrollees 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair replacement. You say that the wheelchair you have is not 
what you need. The Plan denied your request. The Plan says you currently have a wheelchair that is working 
fine, so a replacement is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) may be 
replaced in cases of loss or irreparable damage. Replacement due to wear is not covered during the reasonable 
useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. You currently have a functional power wheelchair that is not lost or 
irreparably damaged. Therefore, there is no need for replacement at this time. Based on this information, we 
decided that Medicare rules for coverage of power wheelchair replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has no mobility. The Plan denied your 
request. The Plan says an IRF admission is not necessary. 
 
The Plan must follow Medicare rules. The rules say that an 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 there are no complex nursing or rehabilitation needs. While the enrollee may 
need 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 
this 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's left upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 services. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has adequate upper extremity strength and mobility to operate the standard switches. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 
23, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not supported by the documentation. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 
 We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that the services rendered were performed by a physical therapist in a home health or hospice setting. This 
means there is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 23, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, 
K0108 - Accutrac motor assembly, elbow positioning support pad, egg switch mount, bracket assembly 
footplate with extension with mounting hardware, Unilink additional link 2.0, QLogic3 expandable joystick 
module, flat hand pad - medium, controller enhanced color graphical display controller). 
 You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the power lift seat and seat elevation is not medically necessary as there is no medical purpose. The 
elbow rests are denied as duplicative. The egg switch mount is duplicative of the sip and puff system and the 
foot plate system is duplicative of the group 3 wheelchair system 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a power wheelchair (E2300, K0108 - Accutrac motor assembly, 
elbow positioning support pad, egg switch mount, bracket assembly footplate with extension with mounting 
hardware, Unilink additional link 2.0, QLogic3 expandable joystick module, flat hand pad - medium, controller 
enhanced color graphical display controller).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 23, 2021, to June 21, 
2021. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that certain data elements are required. Any claim with 
incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. 
 
Review of the file shows that there is no documentation of a completed recertification statement. There is no 
physicians estimate of how much longer skilled services are anticipated to be needed. As the claim is missing 
required documentation, no payment can be made on this claim. Therefore, we decided that the Plan does not 
have to pay for the home health services provided May 23, 2021, to June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) (64493, 64494). 
 
You asked the Plan to pre-approve MBBs. You say that the injections are medically necessary. The Plan denied 
your request. The Plan says the requested MBBs are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation does 
not support that the enrollee had 80% relief from primary pain from the previous treatment. Therefore, the 
reviewer found that the requested MBBs are not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medial branch blocks (MBBs) (64493, 64494).
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 the medical records do not support the need for an intensive 
rehabilitation therapy program consisting of at least 3 hours of therapy per day, at least 5 days per week. The 
Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee 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. Medically necessary care can be provided in a different level of care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the clinical notes provided support the need 
for the requested device. The Plan denied your request. The Plan says the requested home ventilator would be 
set in (IVAPS) mode that could be delivered by BiPAP, and therefore is non-covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has a diagnosis of chronic obstructive pulmonary disorder (COPD), although 
there are no pulmonary function tests to confirm or assess severity.  There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease.  There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that the visits are necessary. The Plan 
denied your request. The Plan says maintenance therapy is not considered to be medically reasonable or 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this physician's review, the file, and Medicare rules. When further clinical improvement cannot 
be reasonably expected from ongoing care, the care is considered maintenance. Based on this information, we 
decided that Medicare rules for coverage of additional chiropractic visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional chiropractic visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) 
(62323). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that this procedure is medically 
necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the epidural steroid 
injection is not reasonable or necessary at this time. 
 
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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found There is no imaging and the documentation that would support an Epidural 
steroid injection is deficit. Therefore, at this point, the request is deemed not medically reasonable and 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features for a leg prosthesis (L5629, L5668, 
L5785, L8470). 
 
You asked the Plan to pre-approve the additional features. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no evidence of a below knee amputation. 
 
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 additional features. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the partial foot prosthesis exceeds what is necessary to meet the enrollee's needs. 
The partial foot prosthesis has not been shown to impact function better than appropriately fitted shoes and 
brace. 
 
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 additional features have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional features for a leg prosthesis (L5629, L5668, L5785, L8470).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc (J7325) injection. 
 
You asked the Plan to pre-approve the injection. You say that you are tired of being in pain. You say that the 
medications you are taking are not helping. You also say that the pain is so much that you cannot get out of bed 
sometimes. The Plan denied your request. The Plan says the requested injection 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 the injection. Our reviewer says that the 
requested Synvisc injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found Synvisc is indicated for the treatment of pain in osteoarthritis of the knee in patients who have 
failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics. The reviewer 
found that the provided medical records do not document trial and failure of conservative nonpharmacologic therapy in this case. Therefore, the reviewer found that the requested Synvisc injection is not medically 
reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Synvisc (J7325) injection.  
 
Benefits for the injection may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.