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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria 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 IRF admission was not medically necessary based on no acute rehabilitation nursing needs and based on his inability to endure the intensity of IRF therapies with functional mobility. 
Documentation did not support the medical necessity for admission to an IRF. The enrollee's rehabilitation 
needs could have been met safely and provided at a lower intensity and alternate setting such as in an SNF. 
 
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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you had surgery on your hip, and your surgeon 
has recommended that you use a shower chair. The Plan denied your request. The Plan says this 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 a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from August 26, 2021, through 
August 28, 2021. 
 
You asked the Plan to pay for the hospital services. You say that this claim has been billed correctly. The Plan 
denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations. 
 
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 find looked at the file and Medicare rules. In this case, this claim has been billed with code J7606. Under 
the Hospital Outpatient Prospective Payment System, this code has a Payment Status Indicator of M which 
indicates that this code is not payable. This code returns a line item edit under the Outpatient Code Editor 
indicating that the claim will be returned to the provider until the unbillable code has been removed. Based on 
this information, we decided that Medicare rules for coverage of the hospital services have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital services provided from August 26, 
2021, through August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen. 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that a CT scan of the abdomen is 
medically necessary. The Plan denied your request. The Plan says a CT scan of the abdomen is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the abdomen. Our 
reviewer says that a CT scan of the abdomen is not medically necessary. Our physician reviewer found that the 
enrollees visit to primary care was dated April 19, 2022, at which time the abdominal exam was negative. 
There was no stated plan by her physician to order a CT of the abdomen for any sort of evaluation. Rather the 
plan was to follow-up in the office in 6 months. The medical necessity of the requested CT abdomen has not 
been established. 
 
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 CT scan of the abdomen. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CT scan of the abdomen.
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 you are unable to do anything on your own. The Plan 
denied your request. The Plan says you do not need an intensive team to manage your rehabilitation 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 physician reviewer found 
that you were admitted to the acute hospital for surgical repair of a hip fracture after a hall. Your medical 
problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy 
program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. 
 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 fluid circulating cold pad. 
 
You asked the Plan to pre-approve the requested item. You say that the ice machine is helpful. The Plan denied 
your request. The Plan says the services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. A fluid circulating cold pad with pump (E0218) will be denied as not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the 
requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid 
circulating cold pad.
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. The Plan denied your request. The Plan says the enrollee does not 
have complex care needs that require a coordinated team approach. 
 
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 was admitted to the acute care hospital for a COVID-19 infection and respiratory failure, was 
transferred to skilled nursing and then discharged home. There is weakness and development of a decubitus 
ulcer and pain.  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. While she has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: 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 service is medically necessary. The Plan denied 
your request. The Plan says the service 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 member's medical conditions are stable and there are no complex nursing or 
rehabilitation needs. While the member may have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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. Specifically, medically necessary services are 
being obtained at the enrollee's current level of care. This means admission into an LTACH is not medically 
necessary. 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 surgical services provided to the enrollee on March 10, 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 an appropriate modifier was not billed with this code edit. 
 
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 38500 is a column II code to column I code 38510. 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 surgical services provided to the enrollee on March 10, 2021.
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 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. 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 medically necessary. Our physician reviewer found you were admitted to 
the hospital with necrotizing fasciitis and disease of the bone (osteomyelitis). The records show that you 
require ongoing acute care services that have not been denied. The medical record does not indicate that you 
require services that you are not currently receiving but that would be available at the LTACH facility. The 
LTACH services are 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs transportation to dialysis. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 was transported via 
stretcher to and from dialysis. The records do not show that the enrollee's clinical condition is such that other 
methods of transport would have negative effects. The criteria for coverage are not met and the non-emergent 
ambulance transport is 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 non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 Sensor Kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor Kit. You say that the CGM is necessary. The 
Plan denied your request. The Plan says they spoke with the nurse from the providers office who advised the 
enrollee is only using insulin once daily. 
 
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 does not show the enrollee is using three (3) or 
more insulin shots per day or be on an insulin pump. Based on this information, we decided that Medicare rules 
for coverage of the Freestyle Libre 2 Sensor Kit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Freestyle Libre 2 Sensor Kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. The Plan states the provider was queried and you are not enrolled in a 
clinical trial of the device. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in your 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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and C2624).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 25, 2022. 
 
You asked the Plan to pre-approve SNF care after May 25, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 after May 25, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the enrollee requires the services on an inpatient 
basis, only in a skilled nursing facility 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 after May 25, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after May 25, 2022.
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 can tolerate three (3) hours of therapy 
and requires comprehensive, multidisciplinary team to help manage the enrollee's rehabilitation. You state the 
enrollee also requires monitoring by physical medicine and rehabilitation (PMR) and neurologist which cannot 
be done at a skilled nursing facility (SNF). You state the enrollee is on polypharmacy for their Parkinsons 
which the neurologist wishes to adjust after closely monitoring enrollee's function and progress on the 
rehabilitation unit while the enrollee participates in the BIG and LOUD program offered at another facility. The 
Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 do not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. The 
documents do not support the medical necessity for admission to 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBRT (CPT code 77523). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the literature indicates that PBRT is not the standard of care for prostate 
cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the 
context of a prospective clinical trial. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), brachytherapy with regards to safety and efficacy. 
 The most recent American Urological Association (AUA) guidelines state that proton beam therapy (PBT) 
offers no clinical advantage over other forms of definitive treatment. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PBRT (CPT code 77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the enrollee has 
not had lab testing or other diagnostic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our physician reviewer 
found that a computed tomography (CT) scan showed new linear and nodular opacity extending to the pleura. 
There is not a strong suspicion of malignancy with resolution of some nodular opacities and development of 
other new suspect inflammatory. Therefore, the requested scan 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.