Persius/hicric huggingface dataset:
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 enrollee needs to continue rehabilitation in a 
SNF so that they can go up and down steps and safely navigate through the home. The Plan denied your 
request. The Plan says the enrollee does not meet guidelines and is receiving adequate and necessary intensive 
rehabilitation in the current IRF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehabilitation 
services in an inpatient rehabilitation facility (IRF).  The enrollee has tolerated inpatient rehabilitation services 
and continues to improve with daily skilled nursing and/or skilled therapy services.  She could benefit from 
continued services at the current level of care.  The enrollee has made slow progress with therapy and there is 
no indication that transfer to a skilled nursing facility is required.  She can continue to receive skilled 
rehabilitation services at the current IRF or be stepped down to a lower level of care when appropriate.  
There are no services offered at a SNF that are not offered at an IRF.  Admission to a SNF for inpatient skilled 
rehabilitation 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that without this procedure you cannot wear 
your top denture. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of lateral exostosis (D7471 x 2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the homemaker services. 
 
You asked the Plan to pre-approve the homemaker services. You say that you need someone to clean your 
house and you do not know why it is not covered. The Plan denied your request. The Plan says the requested 
services is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the homemaker services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the 
homemaker services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you have no other way to get to your appointments. 
The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is at high risk of developing 
lymphedema. The Plan denied your request. The Plan says the services are considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that Bioimpedance spectroscopy devices for detection of 
lymphedema are considered investigative and unproven. The items/services at issue in this case are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bioimpedance spectroscopy (93702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this service will benefit 
the enrollee. The Plan denied your request. The Plan says the information given to us shows that the enrollee 
does not have problems that need 24-hour care. The enrollee's mood is better. He does not have thoughts or 
plans to harm himself or others. He does not hear voices telling him to harm himself or others. He is taking his 
medicine. He can continue treatment outside the hospital. He does not need this level of care for safe and 
effective treatment. 
 
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 hospital services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon review 
the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations 
and without aggressive behaviors while not showing any acute threats of safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care. The health 
plans denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require 
inpatient mental health treatment beyond the dates in question as noted above as 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. It appears that the services were supervised and evaluated by a physician. Based upon 
review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of March 7, 2023, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
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 hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 39561, 43631, 47379, 
49655) provided to the enrollee on October 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 39561: 
 
Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) 
 
CPT 43631: 
 
Gastrectomy, partial, distal; with gastroduodenostomy  
CPT 47379: 
 
Unlisted laparoscopic procedure, liver 
 
CPT 49655: 
 
Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or 
strangulated 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
include enough documentation to confirm that CPT 39561 and CPT 43631 were rendered in this case. These 
codes cannot be verified. In terms of CPT 47379, the provider reported an unlisted procedure for a "liver wedge 
biopsy." In this case, a hernia repair was performed, which would include the biopsy service. The operative 
report does not support this procedure was independent from the hernia repair (CPT 43282). Therefore, this 
procedure cannot be verified. Finally, in terms of CPT 49655, the operative report includes documentation of a 
repair of incarcerated ventral hernia, and a paraesophageal hernia repair. In this case, the ventral hernia repair 
would be included with paraesophageal hernia repair, and not reported separately, as procedure was performed 
through the same incision. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 39561, 43631, 47379, 49655) provided to the enrollee on 
October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle kit sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 shows that the enrollee is using insulin once per 
day. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle kit sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
denture. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 4, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
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 member cannot be safely managed at 
a SNF and requires prolonged hospitalization with intensive skilled services offered in the LTACH setting. The 
Plan denied your request. The Plan says the member 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 there is no documentation provided necessitating admission to a LTACH. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee. The enrollee is receiving appropriate care at the 
present acute care hospital. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 medical records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of 
SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehabilitation 
services in an inpatient rehabilitation facility (IRF).  The enrollee no longer requires daily skilled nursing 
and/or skilled therapy services.  He could benefit from continued intermittent services at a lower level of care.  
Although the enrollee has made progress with therapy, his functional improvement has plateaued. There is no 
indication that transfer to a skilled nursing facility is required.  He can continue to receive skilled rehabilitation 
services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF 
that are not offered at an IRF.  Admission to a SNF for inpatient skilled rehabilitation 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic continuous glucose monitor (CGM) and related supplies.
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 the enrollee requires proper rehab to regain and 
maintain max function. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in their current skilled nursing facility. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance air service provided on January 26, 2022. 
 
You asked the Plan to pay for the ambulance air service. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says after reassessing the entire 
clinical situation, the information provided at the time of appeal does not support criteria for air ambulance 
transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 ambulance air service. Our reviewer says 
that the air ambulance service was not medically necessary. Our physician reviewer found the enrollee was 
hospitalized for pneumonia. Due to the enrollee's prior cardiac transplant, the enrollee was transferred to the 
site of the previous transplant for further care. While having a transplant patient evaluated by a transport team 
is reasonable, it does not appear that the enrollee was acutely in need of transplant services, that the transfer 
was time-sensitive, or that the enrollee was transferred to the closest appropriate facility. As such, the provided 
transport was not medically necessary and reasonable. 
 
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 ambulance air service have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance air service provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial with supporting records. 
The Plan denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the clinical documentation shows that the enrollee has complex functional 
impairments however no active medical comorbidities specified thus the complexity of the enrollee's  
 documented nursing, medical, and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.