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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the admission. Our reviewer says that  
Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears to be at/near a plateau in function. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you believe that you require treatment in 
the SNF setting. The Plan denied your request. The Plan says you do not meet criteria for SNF admission. 
 
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 the SNF admission. Our reviewer says 
that the requested admission to SNF is not medically reasonable and necessary. Our physician reviewer found 
the enrollee is a female who had abdominal surgery in May 2022. She was admitted on June 14, 2022, with 
shortness of breath and right pleural effusion. The enrollee does not have documented skilled nursing 
needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 
feet and tending to daily living activities with minimal supervision. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that  
the enrollee has a history of multiple sclerosis with worsening joint contractures, and spasticity. The clinical 
documentation states that patient has positioning needs that requires power recline and patient is unable to 
effectively relieve pressure with current positioning thus power recline and tilt are medically necessary with a 
group 3 power wheelchair. 
 
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 wheelchair have been met. Therefore, we decided that the Plan has to pre-
approve a group 3 power wheelchair and accessories.  
 
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the requested level of care is not medically necessary and does not meet the 
Medicare guidelines for services in an IRF. The Plan also says that care needs can provided at a lower level, 
such as a Skilled Nursing Facility (SNF) or home health service, upon request. 
 
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 the enrollees nursing, medical, and rehabilitation needs do not 
indicate the need for an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. 
The enrollees medical conditions are stable on mostly outpatient medications with no issues that require a 
physicians evaluation three or more times per week. However, the provided records do not indicate for how 
long intravenous antibiotics will be necessary.  
 
Our physician reviewer also found that while the enrollee does require physical therapy and occupational 
therapy, the medical records do not support a rationale for the necessity of an intensive inpatient rehabilitation 
therapy program over a lower level of care. There is no documentation to support the enrollees ability 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient C5/T1 posterior cervical discectomy and 
fusion. 
 
You asked the Plan to pre-approve inpatient C5/T1 posterior cervical discectomy and fusion. You say that the 
requested inpatient C5/T1 posterior cervical discectomy and fusion is medically necessary. The Plan denied 
your request. The Plan says the requested inpatient C5/T1 posterior cervical discectomy and fusion 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 inpatient C5/T1 posterior cervical 
discectomy and fusion. Our reviewer says that the requested inpatient C5/T1 posterior cervical discectomy and 
fusion is not medically necessary. Our physician reviewer found the enrollee was being treated for spinal 
stenosis of the cervical region. She presented with neck and right arm pain. She has had 2 prior neck surgeries. 
She has significant pain in the posterior neck and right upper extremity. She was recently hospitalized for pain. 
The exam reveals a limited range of motion. There is tenderness present in the cervical spine. There is 
weakness present.  
However, detailed documentation is not evident regarding diagnostic imaging corroborating pathology of the 
cervical spine that would require surgical repair. Additionally, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There is no 
documentation of a trial and failure of any recent physical therapy. She was noted to be seen by pain 
management and was scheduled for an injection. The results of this injection are not evident. Detailed evidence 
of severe and/or progressive neurological abnormalities has not been documented. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested inpatient C5/T1 posterior cervical discectomy and fusion, in 
this case, 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 inpatient C5/T1 posterior cervical discectomy and fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient C5/T1 posterior cervical discectomy 
and fusion.
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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because according to your 
doctor's notes your veins measure less than 4 millimeters in width. 
 
The Plan follows Medicare rules. Medicare rules state that sclerotherapy is only covered under certain 
circumstances. 
 
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 sclerotherapy. Our reviewer says that 
you do not meet the Medicare criteria for sclerotherapy. Our physician reviewer found the documentation 
indicates that your veins measure less than 4 millimeters in width. The 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 the patient remains symptomatic after a 6-week trial of 
conservative therapy. You do not meet the coverage indications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee 
does not have documented skilled therapy needs.  The enrollee is not shown to have an acute decline in 
function. The enrollee is not shown to be able to participate in daily skilled therapy. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization psychiatric admission. 
 
You asked the Plan to pre-approve psychiatric care. You say that this is medically necessary. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because you can be safely 
managed on an outpatient basis. 
 
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 psychiatric care.  Our reviewer says that you do not meet the Medicare criteria for the requested hospital psychiatric program. 
Our physician reviewer found it is not expected that you would improve in a reasonable period of time as you 
did not have dangerousness to self or others and were not showing any auditory/visual hallucinations or any 
aggressive behaviors. It does not appear medically reasonable and necessary to have psychiatric care provided 
at the partial hospitalization level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial hospitalization psychiatric admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically indicated 
procedure. The Plan denied your request. The Plan says this treatment remains experimental. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation is insufficient to support that the Superion interspinous spacer is 
medically reasonable and necessary for the enrollee in this case. The Superion Interspinous Spacer is indicated 
for those patients with impaired physical function who experience relief in flexion from symptoms of 
leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative 
treatment. Implantation of the Superion device has been shown to provide relief of symptoms of intermittent 
neurogenic claudication for patients with moderate lumbar spinal stenosis. The documentation does not support 
that this enrollee has moderate lumbar spinal stenosis with neurogenic claudication. 
 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that the enrollee has already scheduled appointments 
and established care with this provider. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated 
within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 5, 2021.