Persius/hicric huggingface dataset:
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 needs this level of care. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for admission to an 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that you are having a lot of pain. The Plan 
denied your request. The Plan says there is no documentation of neck pain or cervical radiculopathy. 
 The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found you have hip pain. The medical documentation notes a need for a right trochanteric bursa 
injection. There is no physical examination of the neck nor any imaging of the neck. There is no documentation 
to support an epidural injection. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cervical epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve), the SPRINT PNS system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the SPRINT PNS system is 
medically necessary. The Plan denied your request. The Plan says the SPRINT PNS system 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 SPRINT PNS system. Our reviewer 
says that the SPRINT PNS system is not considered medically reasonable and necessary. Our physician 
reviewer found this is considered an experimental/ investigational use of this device. Hayes published SPRINT 
PNS System (SPR Therapeutics) for chronic pain (2020). The report concluded that there is an insufficient 
quantity of published, peer-reviewed, human clinical data to evaluate the use of these devices. 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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (excludes sacral nerve), the SPRINT PNS system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee from April 28, 
2021, to May 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do 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 the denied codes is: 
 
CPT 44810: 
 
Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) 
 
CPT 49000: 
 
Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)  
CPT 64488: 
 
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections 
(includes imaging guidance, when performed) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that an operative report was not 
found, so the denied procedure codes cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee from April 28, 2021, to May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation. 
 
You asked the Plan to pre-approve these services. You say that this procedure is necessary to aid in your 
recovery time. The Plan denied your request. The Plan says that the requested procedure is experimental and 
investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Neuroablation 
remains experimental for low back pain. More research is needed to show safety and efficacy. Our physician 
reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that this device is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is whether the requested authorization for implantation of a Barostim 
Neo system is medically necessary. Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse 
generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. 
The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019 the Food and Drug Administration approved the system for use in 
patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in 
normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable and necessary in this patients clinical management. 
 
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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found that at the time of 
discharge from the hospital the member had stabilized medically. The member did not require any skilled 
nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. The member did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the member did not require any skilled services on an 
inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you received oral medications, had stable 
vital signs and had uncomplicated wound care to your left buttock. You were at a maximal assist level for 
functional mobility. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services (97802, 97803, 
99205). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you need a nutritional 
consultation to optimize your diet to prevent recurrent hypoglycemic episodes. Your provider states there are 
concerns that your fluctuating glucose levels may be contributing to neurological symptoms. The Plan denied 
your request. The Plan says the request indicates your diagnosis is for hypoglycemia, generalized idiopathic 
epilepsy and epileptic syndromes not intractable without status epilepticus. No mention of renal disease or 
diabetes. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services (97802, 97803, 99205).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you received oral medications, had 
stable vital signs and were at minimal to maximal level for functional mobility. You do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee needs continued therapy to regain 
their prior level of functioning after a right hip fracture, bladder infection, and blood transfusion. The enrollee 
does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The Plan denied 
your request. The Plan says the services are not reasonable and necessary. 
 
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 the admission. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you still need prolonged physical therapy. 
The Plan denied your request. The Plan says they will cover up to 100 days each benefit period. You will have 
exhausted the allowed 100 days in a benefit period as of 7/04/22. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from December 29, 2021, 
through July 4, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker with seat attachment (E0149, 
E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker with seat attachment. You say that you could injure 
yourself if trying to get around without the assistance of a walker. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for patients over 
300lbs. 
 
We looked at the file and Medicare rules. The record shows that the enrollee is 271lbs, less than the 300lbs 
required to meet coverage criteria for a heavy-duty walker. Based on this information, we decided that 
Medicare rules for coverage of a heavy-duty walker with seat attachment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty walker with seat attachment (E0149, E0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench (E0247). 
 
You asked the Plan to pre-approve a transfer bench. You say that you would like to shower without slipping or 
falling. The Plan denied your request. The Plan says the requested item is not covered because it is considered 
comfort or a convenience item/hygienic equipment that is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a transfer bench is not covered because it is not 
primarily medical in nature.  
 
While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench (E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the enrollee is currently using 
a home oxygen concentrator and smaller tanks for when she is traveling out of her home, however, a portable 
oxygen concentrator will help keep her COPD from becoming exacerbated. The Plan denied your request. The 
Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD and has a stationary concentrator and portable tanks. The prescribing physician has documented 
(6/7/2022) that the portable tanks are too heavy for the enrollee to carry outside of the home. However, there is 
no walk oximetry test documenting that SpO2 can be maintained greater than 90% using an oxygen conserving 
device with flow 1 - 4 L/min. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).