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 LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because LTACH is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 documentation provided indicates the enrollee is receiving appropriate care at the 
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says there is no medical request for this item. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal if it is determined it is medically necessary. 
We found no exception that would require the Plan to pre-approve these items/services from an OON provider. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be 
provided by an out-of-network (OON) provider.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 enrollee is a 81 year old male with a past medical history of diabetes, 
hypertension, hypothyroidism and prostate cancer who presented to the acute hospital on 03/19/2022 with shortness of breath and lower extremity edema. Based on the medical records provided the complexity of the 
patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The patients medical conditions are stable on outpatient 
medications with no issues that require a physicians evaluation three or more times per week. A medical 
provider note of April 5, 2022, reported the patient was clear to discharge to a skilled nursing facility. The 
patient does require physical therapy and occupational therapy services, but the medical records provided do 
not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Provided records do 
not explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower 
level of care such as in a skilled nursing facility is not appropriate for the patient. In conclusion, there is 
concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility due to his cognitive and endurance limitations. 
Care at the skilled nursing facility level appears to be 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 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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a psychotherapy session you provided on July 12, 2021. 
 
You asked the Plan to pay for the psychotherapy session. The Plan denied your request. The Plan says that the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations, and the date of consultations in the patients medical 
record.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has based their denial rationale on rules that apply to 
Clinical Psychologists. This service was rendered and billed by a Clinical Social Worker. The Plan has not 
forwarded any additional documentation to support why the services at issue are not payable. It is the burden of 
the Health Plan to substantiate their denial with evidence. Therefore, we decided that the Plan has to pay for a 
psychotherapy session you provided on July 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested item is 
experimental/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 a CardioMEMS device. 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 the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system CardioMEMS for management of congestive heart 
failure (CHF) in this patient. The CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) sensor (K0553) 
provided on November 21, 2021. 
 
You asked the Plan to pay for the CGM sensor (K0553). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor (CGM) sensor (K0553) provided 
on November 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99211, 99203, 99202, 99214) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that these services are medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits (99211, 99203, 99202, 99214) to be provided by an out-of-network (OON) provider.
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 this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 completion of treatment at the current acute care location is recommended until the 
patient is more stable and appropriate for a lower level of care. The LTACH does not offer any services that are 
not available in the current 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 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 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. 
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 60-year-old female long term 
care facility resident with a past medical history of diabetes, schizophrenia, seizures, atrial fibrillation and 
bipolar disorder who presented to the acute hospital on February 23, 2022, with altered mental status. In this 
case, there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. Records do not document the need for intravenous medications, 
new tube feeding or ostomy care or daily complex wound care. While this patient does require skilled therapy 
services there is no documentation that daily skilled services are required. Provided records do not clearly 
document a significant decline in the patients functional status compared to her recent baseline to necessitate 
daily inpatient skilled therapy services. Based on the medical records provided there is no documentation that 
the patient requires the services on an inpatient basis, only in a skilled nursing facility setting. Provider records 
do not clarify why services in the long-term care facility on a part time basis would not be 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 admission to a skilled nursing facility (SNF).
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. 
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 daily 
skilled services are not necessary. Our physician reviewer found that the medical record is reviewed in its 
entirety. The member has stabilized medically and is ready for discharge from the hospital. The member does 
not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. The member does not have any parental medication; complex wound care or 
nutrition given via a feeding tube.  He is medically stable without any acute exacerbations of chronic medical 
problems. His physical function is at or near his baseline and he can receive services at a lower level of care.  
He requires custodial care. Admission to a SNF for inpatient skilled rehab services 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95819-26 billed for date of service January 
26, 2021. 
 
You asked the Plan to pay for procedure code 95819-26. You say that the medical records support payment for 
this service. The Plan denied your request. The Plan says this procedure code is not supported in the medical 
record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95819-26 is electroencephalogram (EEG); including 
recording awake or asleep. 
 
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 procedure code 95819-26. Our reviewer says that procedure 
code 95819-26 is not supported in the medical record. Our reviewer found the procedure report does not include sufficient documentation to confirm all criteria in code description (EEG including awake and asleep) 
was performed. To cite the report "This recording showed normal symmetric regular bacground rhythm at 9-10 
Hertz.  There were some motion artefacts,  There was no evidence of sharp waves.  Photic stimulation was not 
done".  Therefore, this procedure 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 procedure code 95819-26 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95819-26 billed for date of service January 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 32 visits and Spravato. 
 
You asked the Plan to pre-approve 32 visits and Spravato. 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 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 32 visits and Spravato. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review of the records provided the enrollee does not meet the Medicare 
guidelines for the use of Spravato/Esketamine as she is diagnosed with bipolar disorder  and has no 
documented treatment failure results based on the PHQ 9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 32 visits and Spravato have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 32 visits and Spravato.
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 passed her swallow test and 
will no longer require corpak. The enrollee is not on a Lasix strip. The Plan denied your request. The Plan says 
authorization denied because LTACH is not medically necessary, and the enrollee is receiving appropriate 
inpatient acute care and is currently unstable for transfer 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 the documentation provided indicates the enrollee is receiving appropriate care at the 
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving 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 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.