Persius/hicric huggingface dataset:
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 does not meet criteria for admission to a long-term acute care hospital because they do not 
require full time access to a doctor or specialized equipment; therefore, the Health Plan physician has 
determined the enrollee's needs can be safely met at a lower level of care. The Plan states the enrollee's Health 
Plan will cover an admission to a skilled nursing facility to continue appropriate treatment without additional 
medical review, if requested within 24 hours. 
 
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 health plans denial of LTACH coverage should be upheld. The enrollee is 
currently undergoing treatment at an ACH for intracranial hemorrhages. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH.  
 The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing LTC 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 has had a very long, 
complicated hospital course and should be admitted to an LTACH. The Plan denied your request. The Plan 
says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can stay in 
the hospital until she is safe for transfer or discharge. 
 
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 on chronic respiratory failure. The record 
indicates that she remains critically ill and requires acute critical 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 she is not currently receiving but that would be available at the LTACH facility. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 pulmonary consult is very difficult to 
obtain from current facility, and this is the primary reason the LTACH is most appropriate. The Plan denied 
your request. The Plan says it is not safe for the enrollee to leave the hospital at this time because their acute 
hospital course is not complete. The Plan states the enrollee does not have a stable respiratory status and they 
are receiving the care they need in the hospital where they are now and there is no need to transfer to the 
LTACH at this time. The Plan states the enrollee can stay in the hospital until they are safe for transfer or 
discharge. 
 
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 dyspnea and hypoxia due to pneumonia. The enrollee 
recently had respiratory decompensation and is 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (0242U) provided on 
August 24, 2021. 
 
You asked the Plan to pay for targeted genomic sequence analysis. You say that the services at issue are not 
subject to the requirement that claims are to be billed with the place of service where the specimen is drawn. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code is generally used to reflect the 
actual setting where the beneficiary receives the face to-face service.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of targeted genomic sequence analysis have not been met. Specifically, this claim was billed with the 
laboratory place of service code while the records indicate that the members face-to-face service was rendered 
in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we 
decided that the Plan does not have to pay for targeted genomic sequence analysis (0242U) provided on August 
24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro 2 Motion G (L8702). 
 
You asked the Plan to pre-approve MyoPro 2 Motion G. 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 MyoPro 2 Motion G. 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 MyoPro 2 Motion G have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro 2 Motion G (L8702).
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 you need the item. The Plan 
denied your request. The Plan says they are currently proving the member with the most appropriate equipment 
that meets their needs and there is no indication an additional portable tank is medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard oxygen tank. a standard oxygen tank serves the same purpose as a 
portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy and occupational therapy visits. 
 
You asked the Plan to pre-approve physical therapy and occupational therapy. You say that physical therapy 
and occupational therapy is medically necessary. The Plan denied your request. The Plan says physical therapy 
and occupational therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 physical therapy and occupational 
therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested PT and OT is 
not generally is accepted as specific and effective therapy for the enrollees condition. The enrollee has had 
prior OT and PT and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee is at a high 
functional level and does not require ongoing skilled therapy for his condition. The requested services are not 
part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy and occupational therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve physical therapy and occupational therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty is covered when medically 
necessary.  
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 total knee arthroplasty. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding formal imaging corroborating advanced arthritis of the left knee. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 19, 2019, 
through March 22, 2019 billed with a principal diagnosis code of A41.51. 
 You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the 
inpatient hospital care as billed. The Plan denied your request. The Plan says the documentation does not 
support the billed principal diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.51, defined as sepsis 
due to escherichia coli. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care 
as billed. Our reviewer says that the documentation does not support the inpatient hospital care billed with a 
principal diagnosis code of A41.51. Our physician reviewer found the review indicates that the enrollee was 
evaluated in the emergency room and admitted to the facility with weakness. The provider assigned diagnosis 
code A41.51 (Sepsis due to escherichia coli [e. coli]) as the principal diagnosis. Physician documentation 
supported the diagnosis; however, the clinical evidence in the medical record does not support the assignment 
of code A41.51.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from March 19, 2019, through March 22, 2019 billed with a principal 
diagnosis code of A41.51.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve posterior cervical instrumentation and lateral arthrodesis from C4 
to T2 with stereotactic navigation for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is the best option to improve quality of life. 
The Plan denied your request. The Plan says that testing does not show instability or worsening deformity or 
cord compression. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was being treated for spondylosis without myelopathy or radiculopathy, cervical region; 
spondylolisthesis, site unspecified; arthrodesis status; spondylolisthesis, cervical region. She presented 2.5 
months postoperative from C3-4, C4-5 ACDF on 9/13/21 and 5.5 months status post C5-6 and C6-7 ACDF on 
6/14/21. She continues to have severe neck and thoracic pain. The 11/30/21 x-rays of the cervical spine are 
noted with impressions of grade 2 anterolisthesis at C7-T1 with 4.5mm of displacement; anterior plating and 
fusion from C3-7. She has previously been fused from C3-C7 via anterior approach, and has been found to 
have adjacent level pathology at C7-T1 with instability evidenced on x-ray. Extending the fusion via posterior 
is indicated to stabilize instability and treat the ongoing severe neck pain. Therefore, the request for posterior 
cervical instrumentation and lateral arthrodesis from C4 to T2 with stereotactic navigation is 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 the surgery have been met. Therefore, we decided that the Plan has to pre-
approve posterior cervical instrumentation and lateral arthrodesis from C4 to T2 with stereotactic navigation 
for the enrollee.  
 
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: 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, or ostomy care or daily complex wound care. You do not require skilled 
services on an inpatient basis, only in a skilled nursing facility setting. Custodial services in the home with 
home health care or in a long-term care facility 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: 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 records do not show they need continued treatments and care that can only be given in a 
hospital setting. The Plans states the enrollee's continued care needs include oxygen and therapy and when they 
are ready to leave the hospital, the enrollee can safely receive this care in another setting, such as a skilled 
nursing facility (SNF) or at home with home health services. 
 
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 improving and should require only short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be 
considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed.  
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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 visits for Hyperbaric Oxygen Therapy (HBOT). 
 
You asked the Plan to pre-approve the 30 visits for HBOT. You say that you would like reconsideration 
because this therapy is medically necessary. The Plan denied your request. The Plan says there is no indication 
that HBOT is used for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that HBOT is limited to specific conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 30 visits for HBOT have not been met. Specifically, you do not have a condition for which 
HBOT is covered. Therefore, we decided that the Plan does not have to pre-approve 30 visits for Hyperbaric 
Oxygen Therapy (HBOT).