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 enrollee needs inpatient rehabilitation to recover. 
The Plan denied your request. The Plan says the enrollee does not have complex rehabilitation needs. 
 
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 physician reviewer found 
that the enrollee is receiving home health services after treatment in an acute hospital and a skilled nursing 
facility for a left hip fracture due to a fall. He has been seen by orthopedics recently and the left hip is healing 
well after surgical repair. He is minimally ambulatory and requires extensive assistance for transfers and activities of daily living. He 
otherwise is reported to be medically stable on outpatient medications. Transfer to an acute inpatient 
rehabilitation facility is requested. The enrollees medical conditions appear stable on outpatient medications 
with no issues that appear to require a physicians evaluation three or more times per week. The provided 
medical records do not explain why the intensive inpatient rehabilitation therapy program is necessary or why 
therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the enrollee. There is 
no documentation that the enrollee requires the intensive medical care and the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combination bilateral lumbo-sacral, hip, femur orthosis 
provided on April 11, 2022. 
 
You asked the Plan to pay for the combination bilateral lumbo-sacral, hip, femur orthosis. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the item rendered is 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 relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that this service was related to a prohibited telemarketing contract. The 
enrollee was not prescribed a hip brace during physical therapy and has not used the brace provided. The 
documentation does not include medical records to support the necessity of the item rendered. 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 combination bilateral lumbo-sacral, hip, femur orthosis 
provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of both Oral Bisphosphonates and Zoledronic Acid is required before alternatives 
can be considered. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows a trial of only one of the plan 
preferred drugs. There is no documentation that Zoledronic Acid would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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. Your wife says you are currently in the hospital, your inpatient 
rehabilitation was denied and you can hardly walk or talk. The Plan denied your request. The Plan says you do 
not meet the criteria for admission to an IRF. 
 
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 18, 2022 with Parkinson's 
disease, urinary tract infection, and altered mental status. You also have a chronic Foley in place, have 
dysphagia and underwent percutaneous endoscopic gastrostomy tube placement on August 23, 2022. You are 
medically stable and no new or acute medical issues are documented. Comorbid conditions are all stable. You 
are left with debility and are ready for discharge to rehabilitation per the medical doctor. 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. 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 the IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation to get to doctor appointments. The Plan denied your request. The Plan says that this request 
exceeds 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 forty-eight (48) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of 48 routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. 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. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve Farxiga. You say that the enrollee has been stable on this medication and 
needs to continue this therapy. The Plan denied your request. The Plan says the requested drug is considered 
self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Farxiga.  
 Benefits for Farxiga 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: 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 admission is necessary. The Plan denied your 
request. The Plan says admission to an acute inpatient rehabilitation facility cannot be covered for the enrollee 
per Medicare rules. 
 
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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proctosigmoidoscopy services coded 45300 provided on 
November 12, 2021. 
 
You asked the Plan to pay for the proctosigmoidoscopy services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 45300 is Proctosigmoidoscopy, rigid; diagnostic, with or 
without collection of specimen(s) by brushing or washing (separate procedure). 
 
 
 We find that CPT code 45300 is not supported in the medical record. Specifically, this service is documented in 
the operative note; however, this procedure is considered inclusive to code 44207 (surgical laparoscopic partial 
colectomy with anastomosis and coloproctostomy). Therefore, this code cannot be separately paid. Based on 
this information, we decided that Medicare rules for coverage of the proctosigmoidoscopy services have not 
been met. Therefore, we decided that the Plan does not have to pay for the proctosigmoidoscopy services coded 
45300 provided on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam by pathologist (88305) billed for date of service 
September 9, 2021. 
 
You asked the Plan to pay for code 88305. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service was not billed in accordance with Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that providers must report services correctly. The rules say that payment is not made under 
the physician fee schedule for Technical Component (TC) services furnished in institutional settings where the 
TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. In addition, TC 
services furnished by independent laboratories to hospital patients are not payable by the MAC. 
 
We find that CPT code 88305 is a pathology service which has both a professional component (PC) and a 
technical component. This service was not billed with modifier 26 to indicate that only the professional 
component payment is requested. This means that payment is requested for both the PC and TC of this service. 
However, this service was provided to an enrollee who was in an outpatient hospital setting at the time the 
sample was collected, which means that the TC component is bundled into the facility payment. The TC 
portion of this service is not payable in this case, and therefore this service is not supported as billed. Based on 
this information, we decided that Medicare rules for coverage of code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for tissue exam by pathologist (88305) billed for date of service 
September 9, 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 February 1, 
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 February 1, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the only option 
for a safe discharge for the enrollee due to the need for frequent nursing care, hourly respiratory care, therapy 
care, wound care, daily physician management, and aggressive oxygen weaning for medical management after 
a cardiac arrest. The Plan denied your request. The Plan says we cannot approve the request for LTACH 
admission because they don't meet the conditions for the stay. The enrollee could have the care needed at an 
alternate level of care like a skilled nursing facility, or at home with home health care services. 
 
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 has a past medical history of hypertension and coronary artery disease 
who presented to the acute hospital on August 1, 2022 with a cardiac arrest. The enrollee was resuscitated and 
treated in the hospital intensive care unit with cardiology involvement. The enrollee required emergent surgery 
for a left hand compartment syndrome.  The enrollee was intubated and mechanically ventilated and has had a tracheostomy placed as well as a 
percutaneous feeding tube. The enrollee does not respond to verbal or physical stimulation and is reported to 
have severe anoxic encephalopathy with a guarded prognosis. Records indicate transfer to a long-term acute 
care hospital has been requested by the family despite her poor neurological prognosis. The enrollee is 
receiving appropriate care at the present setting. The enrollee does not require services at the LTACH that are 
not available at the acute care setting 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that your hand is getting worse every day and want to 
see if acupuncture will work before getting surgery. The Plan denied your request. The Plan says your records 
do not show you have low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back 
pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) 
system. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee would benefit from using 
Dexcom G6 continuous glucose monitoring system which would allow her to increase insulin dose and to 
achieve 
better glycemic control with lower risk of hypoglycemia. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested device. 
 
 
 
 
 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 a Dexcom 
G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitoring (CGM) system.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission has 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 was admitted for wrist fracture, pelvic fracture, and lumbosacral fracture 
after a fall from a ladder. Medical problems are stable and there are no complex nursing or rehabilitation needs.  
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.