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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for respiratory failure, pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on November 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  We looked at the file and Medicare rules. In this case, the services were billed with POS code 22. However, the 
records show that the enrollee was under inpatient status at the time the services were rendered. This means 
that the services were billed with the incorrect place of service. 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 the services (71045) provided on November 15, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be currently unstable and requires additional acute care 
services that can be safely administered at the current facility until more stable. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
may be considered when treatment has completed and the enrollee is more stable. 
 
 
 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: 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 daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support that it is 
medically reasonable and necessary to provide skilled therapy services on a daily basis.  As a practical matter, 
the enrollee does not require the necessary services on 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three units of needle electromyography (95870) provided on 
February 1, 2021. 
 
You asked the Plan to pay for needle electromyography. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that these services were billed with diagnosis code M84.48XA, 
which is not an indicated diagnosis for these services per the Local Coverage Article.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that there are specific diagnosis codes that support the medical 
necessity of Current Procedural Terminology (CPT) code 95870. Any diagnosis codes not listed do not support the medical necessity of this service. 
 
We find that CPT code 95870 is not supported in this case. Specifically, the diagnosis code billed on this claim 
is not included on the list of appropriate diagnosis codes to support the medical necessity of CPT code 95970. 
Based on this information, we decided that Medicare rules for coverage of needle electromyography have not 
been met. Therefore, we decided that the Plan does not have to pay for three units of needle electromyography 
(95870) provided on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 11, 2021, to October 
13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay provided was 
medically necessary. The Plan denied your request. The Plan says that the required services could have been 
provided under observation care. 
 
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 an inpatient level of care was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 11, 2021, to October 13, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, 
E0955, E1007, E1012, E1028, E2311, E2313, E2377, E2604 and E2361).  
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that please review the 
attached documentation and evaluation from the physician The Plan denied your request. The Plan says the 
requested service and codes do not meet the medical necessity requirements of the LCD. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the enrollee does not have a neurologic disorder with 
functional deficits. The documentation does not indicate that the enrollee has any pressure injuries or requires 
intermittent catheterization of the bladder. She has normal tone and there is no spasticity. The requested group 
3 power mobility device is 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 the power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, E0955, E1007, 
E1012, E1028, E2311, E2313, E2377, E2604 and E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Specifically, the record shows that the claim was billed 
with only one diagnosis code, F06.8.  This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology 
code. 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 the services provided on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. 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. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the nerves of the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve the SI joint RFA procedure. You say that you feel that this should be 
covered to treat your pain. The Plan denied your request. The Plan says the requested treatment is experimental 
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 the SI joint RFA procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed 
using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 the SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the nerves of the sacroiliac (SI) joint.
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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with a rolling walker with stand by assistance and is contact guard to minimum assist for transfers. 
Provided records do not document a significant decline in your functional status compared to your recent 
baseline to necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term 
care facility on a part time basis appear 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre system for the enrollee. 
 
You asked the Plan to pre-approve the Freestyle Libre system. You say that the Freestyle Libre system is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet all of the required 
Medicare criteria for coverage. The Plan also notes that the enrollee is restricted to using network providers for 
this type of equipment. Had the enrollee met criteria, they still would be denied for seeking out of network 
services.  
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform 
blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with 
their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre system have not been met.  
It is also noted you are not a network provider with the Plan. The Plan did not authorize the enrollee to see 
treatment out of network. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 
system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
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 pneumonia, Parkinson's disease and falls. 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 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories 
(E0961, E2211, E2213, E0973, E0971, E0978, E2607, E2613, and E220). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and accessories. You say that the current 
chair is falling apart, and the new wheelchair will serve the enrollee's needs much better. The old chair is a 
hazard and continuing to fail as it relates to the breaks and numerous other reasons. The enrollee needs a new 
wheelchair in terms of her posture and support. You also say that the enrollee states she could not use the 
electric chair because the facility is going to charge $25 extra a month. The Plan denied your request. The Plan 
says both wheelchairs have not met their five-year useful life and there is no justification the two current 
wheelchairs cannot meet the enrollees needs. 
 
The Plan follows Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is determined through program instructions. In the absence of program instructions, A/B MACs may 
determine the reasonable useful lifetime of equipment, but in no case can it be less than five years.  
 
The file shows that you currently have two wheelchairs, a manual wheelchair which was approved in April of 
2018 and a power wheelchair that was approved in April of 2019. The file also shows that manual wheelchairs 
were previously determined not to meet the enrollees medical needs and the power wheelchair was determined 
to meet the enrollees needs. The file also shows that both enrollees wheelchairs are within the five-year useful 
life. This means that Medicare rules for coverage of a manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories 
(E0961, E2211, E2213, E0973, E0971, E0978, E2607, E2613, and E220).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on November 20, 2020. 
 
You asked the Plan to pay for continuous neurophysiology monitoring. You say that this service was necessary 
and is supported in the record. The Plan denied your request. The Plan says this service was billed with a CPT 
code that is not recognized by Medicare. 
 
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, CPT code 95941 has a status code indicator of I  not valid for Medicare purposes. Medicare 
uses another code for reporting of, and payment for, these services. (Code not subject to a 90-day grace period.) 
 
We find that CPT code 95941 is not supported in the medical record. Specifically, the reported code is not valid 
for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of continuous 
neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous intraoperative neurophysiology monitoring (95941) provided on November 20, 2020.