Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness after recent cervical spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool. 
 
You asked the Plan to pre-approve a tub stool. The Plan denied your request. The Plan says it is considered a 
convenience item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
We looked at the file and the rules. While a shower chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub 
stool.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 Breathe Non-invasive Open Ventilation 
System (NIOV). 
 
You asked the Plan to pre-approve the Life2000 device. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. The rules also say that all options, supplies and accessories are considered included in the 
monthly rental payment for oxygen equipment.  
We looked at the file and Medicare rules. Review of the file shows that the requested item (the Life2000 
device) is not considered a home ventilator. The requested device is considered an accessory to oxygen 
equipment and cannot be billed separately. Based on this information, we decided that Medicare rules for 
coverage of the Life2000 device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Life2000 Breathe Non-invasive Open Ventilation System (NIOV).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied services with medical 
records. The Plan denied your request. The Plan says the records show that it is not reasonable to expect that, or 
fully benefit from, the intensity of services of an IRF. The enrollee is not able to participate in 3 hours of 
therapy 5 days a week or 15 hours of therapy a week; in the hospital the enrollee has required significant 
assistance to walk a very short distance. The enrollee can safely receive the services they need in other settings 
like a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for congestive heart failure, acute kidney insufficiency, and urinary tract infection. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the member is toe touch weight bearing and 
unable to have home health with the level of care he needs. You say the enrollee is in need for a two person 
transfer and assistance with daily living needs. The Plan denied your request. The Plan says a SNF admission is 
not reasonable and necessary and does not meet Medicare criteria for SNF coverage under the Medicare Part A 
benefit. 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 services. Our reviewer says that 
SNF services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee 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. The records do not document the need for intravenous 
medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. The enrollee 
does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist 
are required to safely and effectively provide medically necessary and reasonable treatment. Although records 
document the enrollee is very limited functionally, the provided records do not clarify that the enrollee would 
be best served by daily therapy. A recommendation for "continued slow paced rehab" has been documented 
and the enrollees cognitive impairment is reported to limit his ability to follow therapy commands and 
recommendations. As a practical matter, there is no documentation that the enrollee requires the services on an 
inpatient basis, only in a skilled nursing facility setting. The records do not document that services in the home 
or an assisted living facility with home health care or in a long-term care facility on a part time basis are not 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection wheelchair seat cushion (E2622). 
 
You asked the Plan to pre-approve a skin protection wheelchair seat cushion. You say that the requested item is 
a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a skin protection seat cushion is covered when the 
conditions listed in the Medicare rules section have been met. 
 
 
  We looked at the file and Medicare rules. In this case, the record indicates you do not have a manual 
wheelchair or a power wheelchair. Based on this information, we decided that Medicare rules for coverage of a 
skin protection wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skin protection wheelchair seat cushion (E2622).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specially sized or constructed wheelchair (E1220). 
 
You asked the Plan to pre-approve a specially sized or constructed wheelchair. You say that the requested item 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a 
PMD have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
  The file does not show that the enrollee can safely operate the PMD being requested. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a specially sized or constructed wheelchair (E1220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about you condition you do not meet the requirements. 
 
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 you were admitted to an acute hospital on August 5, 2022 after a fall sustaining 
right hip fracture and underwent right hemi arthroplasty on August 6, 2022 with non-weight bearing on right 
lower extremity. You were transferred to a skilled nursing facility on August 12, 2022 and are requesting an 
IRF admission. You are medically stable and no new or acute medical issues are documented. Comorbid 
conditions are all stable. There are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
While you would benefit from physical and occupational therapy, your needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service November 
17, 2021. 
 
You asked the Plan to pay for procedure code 20936. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20936 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve continuous passive motion device. You say that this is medically necessary. 
The Plan denied your request. The Plan says that this is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you want to have surgery in a location near 
family that is able to take care of you post operation. The Plan denied your request. The Plan says out-of-
network coverage is not provided as in-network services when care is available in the Plan. The Plan also says 
that there is a provider available within the Plan. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a specialist office visit provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion/eversion correction device. 
 
You asked the Plan to pre-approve an inversion/eversion correction device. You say that this device is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is 
statutorily not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that an inversion/eversion correction device (A9285) 
is denied as noncovered (no Medicare benefit), because it does not act as a brace; that is, it does not support a 
weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body. Based 
on this information, we decided that Medicare rules for coverage of an inversion/eversion correction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an inversion/eversion 
correction device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that the enrollee has a diagnosis of giant cell 
arteritis. The appellant says that the enrollee failed hydroxychloroquine due to nightmares. The appellant says 
that the requested drug is medically necessary. The Plan denied your request. The Plan says the medication in 
question is self-administered and is covered under the pharmacy benefit. The Plan says that the enrollee does 
not have a pharmacy benefit under this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.  
 Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a circulating cold pump. 
 
You asked the Plan to pre-approve a circulating cold pump. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says this equipment is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a circulating cold pump have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a circulating cold pump.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility admission provided by a 
participating provider. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that this admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says due to the enrollee refusing 
to participate with the therapist, these services are not medically necessary. 
 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 a skilled nursing facility admission. Our 
reviewer says that a SNF admission is not medically necessary. Our physician reviewer found daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs are custodial and 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 a skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility admission provided by a participating 
provider.