Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services, per 15 minutes 
(H2017). 
 
You asked the Plan to pre-approve the behavioral health services. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does 
not meet medical necessity criteria for the requested psychosocial rehabilitation services but would benefit 
from individual therapy services. 
 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 outpatient services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee is being treated for Chronic Depression, Insomnia and Anxiety. Based 
on review the records provided, there is no documentation of this enrollee showing depressive symptomatology 
that would require this type of service. This enrollee does not have any suicidal or homicidal thoughts which 
would require Psychosocial Rehabilitation Services (PSR). Based on review and utilizing LCD L34616, this 
enrollee does not require treatment utilizing Psychosocial Rehabilitation Services (PSR) but could be treated on 
an outpatient basis by his doctor along with therapy and therefore is not considered reasonable or 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 the behavioral health services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve psychosocial rehabilitation services, per 15 minutes (H2017).
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 admission to the SNF will help the enrollee reach 
maximum function. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to a SNF. 
 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 medical records do not document the need for daily inpatient skilled nursing 
services. Although the patient is very limited functionally, provided records do not document a significant 
decline in the patients functional status to necessitate daily inpatient skilled therapy services. The enrollees 
care needs can be provided at a lower level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an energy storing foot and multi-axial rotation unit for a 
lower limb prosthesis 
 
You asked the Plan to pre-approve prosthetic foot components. You say that you need a whole new prosthetic 
leg. The Plan denied your request. The Plan says the requested K3 level foot is not supported for you, and a K2 
level foot could meet your needs instead. 
 
The Plan follows Medicare rules. Medicare rules state that coverage of lower limb prosthetic components is 
based on an assessment of the enrollees functional level. 
 
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 prosthetic foot components. Our 
reviewer says that you do not meet the Medicare criteria for the requested prosthetic components. Our 
physician reviewer found the records do not support that you are a K3 level ambulator as is required to meet 
criteria for these components. The latest office visit note reported that you were unable to walk independently 
and required a walker, and you were using a wheelchair at the time of the visit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic foot components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an energy storing foot and multi-axial rotation unit for a lower limb 
prosthesis
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Verquvo. 
 
You asked the Plan to pre-approve Verquvo. The Plan denied your request. The Plan says Verquvo is a benefit 
exclusion. 
 
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 Verquvo.  
 
Benefits for Verquvo 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) services. 
 
You asked the Plan to pre-approve HBOT services. You say that HBOT is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the records show that the 
enrollee does not have optimization of nutritional status and glucose control. 
 
The Plan follows Medicare rules. Medicare rules say that HBOT is covered for certain medical indications. 
 
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 HBOT services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of diabetes, 
hypertension, renal cell cancer, and venous insufficiency with a diagnosis of diabetic ulcer of left ankle with 
necrosis of bone and subacute osteomyelitis of left ankle after undergoing a left trans-metatarsal amputation. 
The records show that the wound has been present since at least September 16, 2022. Additionally, records 
indicate that he had magnetic resonance imaging on September 28, 2022, that showed that bone was also 
infected. He has been on antibiotics for at least four weeks. He had an Ankle Brachial Index (ABI) on October 
18, 2022, that was negative for arterial disease. There is no documentation regarding his nutrition and control 
of diabetes. He is currently offloading with Darco shoe. He has also been receiving weekly wound care with 
cleaning of the wound and specific dressing to help the healing process. Despite all this the wound has not 
improved in size in the last 30 days. The review has determined that the criteria for coverage have not been met 
as there is no documentation indicating optimization of nutritional status and glucose control. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee's behavior has not changed after a previous admission. 
 
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 mental health care. Our 
reviewer says that the record does not show that inpatient mental health care is medically necessary at this time. Our physician reviewer found the enrollee does not meet criteria for acute inpatient mental health treatment as 
he was not shown to be a danger to himself or others and had no auditory or visual hallucinations. 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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency, inpatient hospital services received out of the country 
(Ireland) provided February 23, 2022. 
 
You asked the Plan to pay for the hospital services. You say that your 2022 Evidence of Coverage that you may 
get emergency medical care whenever you need it, anywhere worldwide. The denial should be reversed, and 
the bill should be paid without further delay. The Plan denied your request. The Plan says that the requested 
services are not medically necessary. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 hospital services. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue in this case is whether the hospital services provided in Ireland for February 23, 2022 
for an acute stroke are eligible for coverage under Medicare guidelines.  Based on the medical records provided 
the enrollee could not have reasonably been expected to foresee requiring the services prior to leaving his 
service area. The records indicate that the care provided was medically necessary and emergently and urgently 
needed. The enrollee presented with acute neurologic symptoms and a magnetic resonance scan of the brain 
showed acute infarcts.  Based on the medical records provided it would not have been medically reasonable to 
delay the services until the date when the enrollee returned to his service area. 
 
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 hospital services have been met. Therefore, we decided that the Plan has to 
pay for the emergency, inpatient hospital services received out of the country (Ireland) provided February 23, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography. 
 
You asked the Plan to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image 
guidance (fluoroscopy or CT) including arthrography. The Plan denied your request. The Plan says the 
requested injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) 
including arthrography is 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 injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography. Our reviewer says that the 
requested injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) 
including arthrography is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, there is no documentation on physical examination of tenderness of the SI joint 
and no mention of SI provocative testing being completed with positive findings. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. The review has determined that the enrollee does not 
have a diagnosis/condition that meets the criteria for the requested services.  The requested sacroiliac joint 
injection is 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 injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography.
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 necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for admission to an inpatient rehabilitation 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a pathologic femur fracture. Your 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 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 you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound, aortography, and angiography 
provided to the enrollee on March 30, 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 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure)  
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 in terms of CPT 37253, the 
operative report does not include documentation of additional noncoronary, vessel intravascular ultrasound. In 
terms of CPT 75625, the operative report does not include documentation of abdominal aortography. In terms 
of CPT 75710, the operative report describes extremity angiography, however an intervention was performed, 
and would include angiograms/venograms. Therefore modifier -59 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intravascular ultrasound, aortography, and angiography provided to the enrollee on March 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgery (perforator vein ligation with skin 
graft). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that perforator vein ligation is covered when specific 
criteria 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have varicose veins with no active 
symptoms. The records do not document failure of conservative therapy. The criteria for coverage are not met 
and the requested procedure is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vascular surgery (perforator vein ligation with skin graft).
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 necessary. The Plan denied 
your request. The Plan says an IRF admission 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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur fracture after a fall. 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 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 you 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.