Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient stay for an electroencephalogram (EEG), 
continuous recording, physician or other qualified health care professional review of recorded events, analysis 
of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) 
(95718) and an electroencephalogram (EEG), continuous recording, physician, or other qualified health care 
professional review of recorded events (95720). 
 
You asked the Plan to pre-approve an inpatient stay for EEG monitoring. You say that you disagree with the 
denial. The Plan denied your request. The Plan says there is no evidence that this enrollee has any objective 
complications that require an acute inpatient admission. 
 
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 an inpatient stay for EEG monitoring. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found it is noted that breakthrough seizures can cause threat to life and bodily 
function, as well as serious injuries. The enrollee has had inconclusive routine EEGs and continues to 
experience episodic events where epilepsy is suspected but the history, examination, and routine EEG 
recordings have not resolved diagnostic uncertainties. The enrollee needs to be closely monitored for potential 
serious events, medication side effects, medication interactions, and toxicity. It has not been sufficiently 
established at this time that an inpatient hospital admission is medically necessary for the requested continuous 
EEG monitoring. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient stay for EEG monitoring have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient stay for an electroencephalogram (EEG), continuous 
recording, physician or other qualified health care professional review of recorded events, analysis of spike and 
seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) (95718) and an 
electroencephalogram (EEG), continuous recording, physician, or other qualified health care professional 
review of recorded events (95720).
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 IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare 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 that the enrollee is medically stable and does not need a physical medicine and rehabilitation physician's supervision three times a week in an IRF. There are no acute rehabilitation nursing 
needs identified or documented. At the current level, the enrollee does not need intensive therapies consisting 
of at least three hours of therapy per day at least five days per week with multidisciplinary approach in an IRF. 
The documentation does not support necessity for admission to an IRF due to lack of medical or rehabilitation 
complexity and acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and 
occupational therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medicare will cover a device called respiratory assist device that has 
advanced features, and the plan will cover this when medically necessary. The plan must follow Medicare 
rules. 
 
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. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
and found to have an arterial blood gas consistent with severe acute on chronic hypercarbic respiratory failure.  
The enrollee has a prior history of hypercarbic respiratory failure requiring intubation and tracheostomy. The 
enrollee also has obstructive sleep apnea and severe obesity. The enrollee improved in the hospital on BiPAP.  
There are no pulmonary function tests documenting the severity of the COPD. The enrollee may benefit from 
BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that could be provided by BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee's medical diagnosis is 
progress and will likely require on-going physical therapy. The Plan denied your request. The Plan says the 
additional physical therapy services requested are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the documentation, the member's condition has not changed 
with treatment. There is no objective improvement in terms of range of motion or function with continued 
treatment. There is also limited clinical information and history, other than physical therapy documentation 
indicating the member's condition and how ongoing physical therapy will mitigate this. Therefore, the 10 visits 
of additional therapy cannot be considered 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional PT visits.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided July 7, 2022, to August 3, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services are not payable with the diagnosis code 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. 
 
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 home health services. Our reviewer says that the 
documentation supports the diagnosis code billed. Our reviewer found the enrollee was receiving home health 
services. The nursing documentation visit notes provide a detailed wound assessment and wound care that is 
necessary to care for the enrollee. Therefore, the diagnosis of I73.9 (Peripheral vascular disease, unspecified) is 
supported by the documentation.  
 
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 home health services have been met. Therefore, we decided that the Plan has 
to pay for the home health services provided July 7, 2022, to August 3, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 1, 2021, to February 14, 2021. 
 
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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. There is no indication that the 
member received or required isolation due to an infectious disease or that the therapy score was correct. The 1st 
and the 3rd alphanumeric character in the PDPM were not correct.  The partial adjustment to PDPM LAQD1 
was appropriate. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from February 1, 2021, to 
February 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy. 
 
You asked the Plan to pre-approve a colonoscopy. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that colonoscopies are 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 a colonoscopy. Our reviewer says that 
the services are medically necessary. Our physician reviewer found Records as provided do not support that the 
enrollee's flat mid-colon polyp found in 2022 was adenomatous, was incompletely resected, nor that the 2022 
procedure was incomplete. However, repeat colonoscopy with optimal prep is warranted, and meets eviCore 
standard-of-care guidelines COLON-13 which states: "for cases in which the Boston Bowel Prep Scale score is 
not available, repeat examination is as per the endoscopist with documentation (as is present in this case) 
indicating the inadequacy of the prepearation and the need for earlier-than-usual follow-up." 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy.  
 
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: 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 IRF care. The Plan denied your 
request. The Plan says because this enrollee's medical and therapy needs can be met at a less intensive level of 
care, the request for 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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Entresto.  
 
Benefits for Entresto 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the best option for the 
enrollee to have a safe and sustainable discharge. The Plan denied your request. The Plan says all services that 
would be provided in the LTACH are being provided in the current acute care setting which is already 
approved. 
 
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 that all medically necessary care is being provided in the current acute care setting. 
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 Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral brachioplasty procedure (15836, 15002, 
15003, 15852, 13120, 13121,13122, 12002, 12001, 12004, 12005, 12007, and 12006). 
 
You asked the Plan to pre-approve a bilateral brachioplasty procedure. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that cosmetic surgery or expenses incurred in connection 
with such surgery 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 bilateral brachioplasty procedure. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record provided 
does not document that the requested procedure is to repair an accidental injury or to improve the functioning 
of a malformed body member. The elements of the coverage criteria are not satisfied. The requested service is 
not recommended. 
 
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 bilateral brachioplasty procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral brachioplasty procedure (15836, 15002, 15003, 15852, 
13120, 13121,13122, 12002, 12001, 12004, 12005, 12007, and 12006).
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 recommended to get the enrollee moving 
again to return to prior level of independence. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can 
be provided at a lower level of care. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that procedure code 99223 is an inpatient-
only code billed for outpatient services. However, the case record supports that the claim is for inpatient 
services as place of service (POS) is reported as 21, indicating an inpatient hospital. Additionally, the Plan 
states that code 99223 was billed on a prior claim. The documentation of the prior claim as provided by the 
Plan does not support that code 99223 was previously billed. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service 
August 29, 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.