Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 did not qualify for SNF coverage on April 
18, 2022. You did not have documented skilled nursing needs. You did not have documented skilled therapy 
needs. You were not shown to have been functioning significantly below your baseline. Daily skilled services 
were not shown to have been required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of gastric bypass and hernia repair. 
 
You asked the Plan to pre-approve revision of gastric bypass and hernia repair. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 revision of gastric bypass and hernia 
repair. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested procedure distalization of gastric bypass is 
not considered a standard bariatric procedure at this time. There are small case series, which have also 
documented risk of malnutrition and need for revision. There are no large prospective high-level studies to 
document durability and efficacy. There is no anatomic complication of the prior gastric bypass at this time. 
The enrollee has findings of a 2 cm hiatal hernia but documents no history of gastroesophageal reflux disease 
(GERD) or GERD medication intake. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revision of gastric bypass and hernia repair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve revision of gastric bypass and hernia repair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardio panel for comprehensive cardiovascular genes assay 
for hereditary cardiology screening (81401, 81403, 81404, 81405, 81406, 81407 and 81408) provided August 
30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please reconsider for payment. The Plan 
denied your request. The Plan says this testing is considered a screening service and is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for cardio panel for comprehensive cardiovascular genes assay for hereditary cardiology screening (81401, 
81403, 81404, 81405, 81406, 81407 and 81408) provided August 30, 2021.
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 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 patient appears to be more stable and improving and should require only short-
term additional acute care services that can be safely administered at the current facility until appropriate for a 
lower level of care. The patient 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 patient requires that are not already available and 
covered at the current facility. Transfer to LTACH is 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro power-assisted arm brace. 
 
You asked the Plan to pre-approve the MyoPro brace. You say that the use of this brace will allow the enrollee 
to regain some additional arm function. The Plan denied your request. The Plan says there are not enough 
studies to show this can be considered reasonable and 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 MyoPro brace. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided and current practice guidelines, there is no 
documentation that the requested MyoPro power-assisted arm brace at issue in this case meets Medicare 
criteria for medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of 
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment.  
 Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollee's actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MyoPro brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro power-assisted arm brace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says you do not 
meet the requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is only covered under certain 
medical indications.  The file shows that ExoDx Prostate IntelliScore (EPI) testing was requested. We looked at the file and 
Medicare rules. The records show that your prostate specific antigen (PSA) was at 11.2. The rules say that the 
requested testing is covered with a PSA of less than 10. Based on this information, we decided that Medicare 
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 11, 2021, to July 
22, 2021, as billed with Diagnosis Related Group (DRG) 177. 
 
You asked the Plan to pay for inpatient care billed with DRG 177. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 177 is not supported as the secondary diagnosis of acute and chronic respiratory failure 
with hypoxia (J96.21) is not supported in the medical record. The Plan argues that DRG 178 is more 
appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 177. Our 
reviewer says that the secondary diagnosis of acute and chronic respiratory failure with hypoxia (J96.21) is not 
supported in the medical record. Our physician reviewer found that the enrollee was admitted and treated for 
pneumonitis due to suspected inhalation of food and vomit. Acute and chronic respiratory failure with hypoxia 
(J96.21) was not sufficiently supported in the documentation as the enrollee was reported to not have any 
respiratory distress and oxygen saturation of 91-97% on low dose oxygen (3L). There was no decrease in 
oxygen saturation during treatment or increased oxygen requirement that would meet the definition of acute 
respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 177 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 11, 2021, to July 22, 2021, as 
billed with Diagnosis Related Group (DRG) 177.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you are not insulin treated with multiple daily injections. 
 
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 use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services at issue are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the criteria for acute inpatient mental health treatment. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment ad he was not a danger to himself 
or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. The enrollee was not showing any withdrawal symptoms. He is noted to be cooperative 
and compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration 
because the requested procedure is medically necessary. The Plan denied your request. The Plan says this 
procedure is considered 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 the Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept Procedure is experimental and more research is needed to show its 
safety and efficacy. 
 
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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that you won't have anyone to take 
care of you after the surgery. You say that you are afraid you will fall and hurt yourself. You say that the 
inpatient admission is necessary for your safety. The Plan denied your request. The Plan says that the 
guidelines for coverage of an inpatient stay after the surgical procedure have not been met. The Plan says that 
they will review an inpatient request if medical issues develop. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for an inpatient hospital admission are met in 
this case. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis of 
the right knee. She has been planned to undergo a right total knee arthroplasty. She presented with persistent 
right knee pain. She is getting progressively worse. The enrollee's body mass index is 29.24 kg/m2. The exam 
reveals medial and lateral joint line tenderness. The range of motion is 0-120 with pain at extremes of motion. 
In this case, there is a medical history that could place this enrollee at increased risk for peri-surgical 
complications requiring an inpatient stay.  She has a history of hypertension and T-cell lymphoma stage I. She 
is documented to live by herself. Therefore, the requested inpatient stay after right total knee arthroplasty, in 
this case, 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 an inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital admission.  
 
 
 
 
 
 
 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: 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 attending physician feels the enrollee 
is ready to go to a LTACH. You state the enrollee cannot be adequately cared for at a SNF in their condition. 
You state the enrollee requires prolonged hospitalization and close physician care. The Plan denied your 
request. The Plan says the stay is not medically necessary based on LTACH 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 more stable and improving and should require only short-
term additional acute care services that can be safely administered at the current facility until appropriate for a 
lower level of care. 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 patient requires that are not already available and 
covered at the current facility. Transfer to LTACH is 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper extremity study (93931) provided on June 16, 
2021. 
 
You asked the Plan to pay for the upper extremity study. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support that more than one unit of CPT code 93931 was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the upper extremity study (93931) 
provided on June 16, 2021. have been met. Specifically, the documentation indicates that one unit of CPT code 
93931 has been processed and paid by the Plan. The record does not support that an additional unit of CPT 
code 93931 was rendered on the billed date of service.. Therefore, we decided that the Plan does not have to 
pay for the upper extremity study (93931) provided on June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging (78452) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the myocardial perfusion imaging. The Plan denied your request. The Plan says 
there was no report of, or consideration for, a regular exercise heart stress test; or that patient was unable to 
perform an exercise stress test; or that a chemical stress test could not be done; or that one or the other was 
abnormal or inconclusive. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is covered when any of 
the indications for myocardial perfusion imaging listed in the Rules section above are met. 
 
 
  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 myocardial perfusion imaging. Our 
reviewer says that there is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing in this patients clinical management. Our physician reviewer found at issue is the medical 
appropriateness and necessity of carrying out a radionuclide stress test, rather than a treadmill stress test. The 
patient has a history of chest pains. Our reviewer found that here is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern. Our physician reviewer also found that there is no 
evidence provided that would support the need for radionuclide stress testing. 
 
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 myocardial perfusion imaging have not been met. Therefore, we decided 
that the Plan does not have to pay for the myocardial perfusion imaging (78452) provided on October 11, 2021.