Persius/hicric huggingface dataset:
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 the enrollee's needs more physical therapy to get 
into the assisted living facility. You say that the enrollee is wheelchair bound and their caregiver was their 
father who recently passed away. You say that the enrollee stays with a relative who is unable to care for them 
long term. The Plan denied your request. The Plan says a SNF admission is 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 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral lower extremity ultrasound guided 
sclerotherapy of the greater saphenous vein (GSV). 
 
You asked the Plan to pre-approve a bilateral lower extremity ultrasound guided sclerotherapy of the GSV. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 millimeters in diameter and if the patient remains symptomatic after a six-week trial of conservative 
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 a bilateral lower extremity ultrasound 
guided sclerotherapy of the GSV. Our reviewer says that the documentation does not warrant bilateral GSV 
sclerotherapy and tributary sclerotherapy. Our physician reviewer found the left tributary less than size cutoff 
of 4 millimeters. Our reviewer found that the left leg edema is likely related to knee injury and prior foot 
surgery, while the right leg has no significant symptoms. The documentation does not meet guideline criteria 
for use of this therapy. Our physician reviewer also found that there is insufficient documentation to support 
the medical necessity for the requested venous sclerotherapy in this enrollee's clinical management. 
 
 
 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 lower extremity ultrasound guided sclerotherapy of the GSV have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral lower extremity 
ultrasound guided sclerotherapy of the greater saphenous vein (GSV).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. The Plan denied your request. The Plan says this request is not 
medically necessary per Medicare rules. 
 
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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical necessity of a TTE, in the absence of any apparent cardiac symptoms or 
significant change in the enrollees clinical condition. Clinical guidelines do not support carrying out a TTE 
with no intervening change in clinical status. Our reviewer also found that there is no supportive evidence for 
the medical necessity of repeat TTE in this enrollees clinical management. 
 
 
 
 
 
 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra wide shower chair on wheels. 
 
You asked the Plan to pre-approve an extra wide shower chair on wheels. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
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 an extra wide shower chair on wheels.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is 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 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 6, 2019, to December 24, 2019. 
 
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 several items and services initially denied due to not having an itemized bill have now been 
identified as routine items and services. 
 
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 the items billed separately from 
the "room and the board charges" were denied correctly. Each item billed would be inclusive to the primary 
service provided. They cannot be verified as a separate service. Additionally, the medical record includes 
cardioversion provided on December 16, 2019, however the documentation reviewed does not include 
documentation to confirm the provider was reimbursed for this service.. 
 
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 inpatient hospital services provided to the enrollee from December 6, 2019, to December 24, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 29, 2022, 
through February 04, 2022, and billed with diagnosis code J15.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis J15.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of J15.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code J15.9-Unspecified bacterial 
pneumonia. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
J15.9-Unspecified bacterial pneumonia. Our physician reviewer found the member was diagnosed with fluid 
overload and was treated with dialysis as well as intravenous antibiotics. Also, there was no sputum culture 
confirming bacterial pneumonia. Therefore, without evidence of a bacterial infection in the lungs, the diagnosis 
code J15.9-Unspecified bacterial pneumonia is not supported and not appropriate as the primary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 29, 2022, through February 04, 2022, and billed with 
diagnosis code J15.9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
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 a Group 2 PWC 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 the enrollee is non-ambulatory with 
lumbar arthritis and neuropathy. He does not use a catheter and is not at high risk for skin breakdown. He has 
no skin breakdown or spasticity. The criteria for coverage of a Group 2 PWC are not met and the services are 
therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can safely receive the care they need in the current hospital setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the enrollee meets all necessary LTACH 
admission requirements as this service is benefiting the enrollee to regain strength and tolerance. You also say 
that the enrollee still exhibits some ongoing medical conditions that requires constant medical supervision. The 
Plan denied your request. The Plan says based on Medicare guidelines the long term acute care hospital 
services you are requesting do not meet the requirements for approval. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate for a lower level of 
care soon. The enrollee does not require services at the LTACH that are not available and covered at the current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure mattress. 
 
You asked the Plan to pre-approve a dry pressure mattress. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 The Plan must follow Medicare rules. Medicare rules say that group one mattress overlay or mattress is 
covered if one of the following three criteria are met: 
1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without 
assistance, or 
2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position 
significant enough to alleviate pressure and at least one of conditions A-D below, or 
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below. 
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition 
sufficiently to demonstrate the medical necessity for a pressure reducing support surface): 
A. Impaired nutritional status 
B. Fecal or urinary incontinence 
C. Altered sensory perception 
D. Compromised circulatory status 
We looked at the file and Medicare rules. Review of the file shows that the medical records do not show that 
you are completely immobile, or that you have limited mobility. Additionally, the documentation does not 
show that you have any stage pressure ulcers. Based on this information, we decided that Medicare rules for 
coverage of a dry pressure mattress have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a dry pressure mattress.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myocardial perfusion imaging, tomographic (SPECT); 
multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says under Medicare guidelines, 
the request 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 the outpatient procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has no cardiac symptoms and previous cardiac catheterization in 
October, 2018 showed no significant coronary disease. There is no documentation that the ECG shows an 
uninterpretable pattern or that the enrollee is unable to exercise. There is no evidence provided that would 
support the need for radionuclide stress testing at this time. In summary, there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this enrollees clinical management. 
 
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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest 
and/or stress and/or redistribution and/or rest reinjection (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee takes four doses of insulin 
daily. The Plan denied your request. The Plan says that the coverage criteria has 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CGM and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) (codes 
33361, 33362, 33363, 33365, and 33366) and an associated inpatient stay. 
 
You asked the Plan to pre-approve a TAVR and associated inpatient stay. You say that the enrollee has severe 
aortic stenosis, and is an appropriate candidate for TAVR. The Plan denied your request. The Plan says this 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Transcatheter Aortic Valve Replacement (TAVR) is 
covered for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug 
Administration (FDA)-approved indication 
 
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 TAVR and associated inpatient stay. 
Our reviewer says that a TAVR and associated inpatient stay are not reasonable and necessary for the enrollee. 
Our physician reviewer found the most recent echocardiogram showed aortic stenosis, with valve area over 1 
square centimeter and other hemodynamic parameters which are not sufficiently severe as to warrant valve 
replacement. Guidelines would not support aortic valve replacement based on the submitted medical records. 
Our reviewer also found that at this time, the requested TAVR would not be considered medically necessary in 
this enrollee's clinical management based on the submitted documentation. 
 
 
 
 
 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 TAVR and associated inpatient stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) (codes 33361, 
33362, 33363, 33365, and 33366) and an associated inpatient stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve repeat ESI. You say that the enrollee needs these services. The Plan denied 
your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee had 50% pain relief for 3 months. Therefore, the reviewer found that the requested ESI 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).