Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that for the enrollee to sustain a safe and 
sustainable discharge, an LTACH is the best option for their care. You say that the enrollee can benefit from 
being closely monitored by the nursing staff in an LTACH. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee can safely receive the care they need in another 
setting. 
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 you had a stroke and need more time to work on 
walking on your own or with a small amount of assistance and in getting your balance back. You say you want 
to go home without the fear of falling and have things get worse. The Plan denied your request. The Plan says 
based on Medicare guidelines, the SNF services you are requesting do not meet the requirements for approval. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist however, provided records do not 
document a significant decline in your functional status to necessitate daily inpatient skilled therapy services. 
You do not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. Records support that services in the home with home health care or in a long-term care facility 
on a part time basis are appropriate in this case. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from October 7, 2022, 
to October 9, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you feel that you are being unjustly 
penalized being made to pay $277.75 out of pocket. You also say that this amount is a hardship for you, as you 
live on a fixed income. The Plan denied your request. The Plan says this claim processed correctly, and the 
determination remains upheld. 
 
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 pay for the self-administered drugs 
provided from October 7, 2022, to October 9, 2022.  
 Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, excessive skin and subcutaneous tissue (includes 
lipectomy); leg provided to the enrollee on June 21, 2022. 
 
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 there is a more appropriate code for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15833 is "Excision, excessive skin and subcutaneous 
tissue (includes lipectomy); leg." 
 
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 there is a more appropriate code 
to report a wound debridement. The procedure note states that the diseased tissue was removed and the wound 
was packed. This describes a wound debridement, not excision of excessive skin. The elements of CPT code 
15833 are not satisfied by the procedure report in the medical record.  
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 excision, excessive skin and subcutaneous tissue (includes lipectomy); leg provided to the 
enrollee on June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 29, 2022, 
to July 30, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that admission was warranted as new 
symptomology as concern as multifaceted complaints and significant history. The Plan denied your request. 
The Plan says the enrollee did not meet medical necessity for an inpatient stay, specifically because they did 
not require greater than a two-midnight inpatient stay. 
 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from July 29, 2022, to July 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued use of an oxygen concentrator and portable oxygen 
concentrator. 
 
You asked the Plan to pre-approve continued use of an oxygen concentrator and portable oxygen concentrator. 
You say that the items are medically necessary. The Plan denied your request. The Plan says that you have 
reached the 36-month rental limit. 
 
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. The Plan has not submitted any evidence that they paid for 36 months of rental 
for this item. Therefore, we decided that the Plan has to pre-approve continued use of an oxygen concentrator 
and portable oxygen concentrator.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs to regain strength 
since they cannot function on their own. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary, and the enrollee can safely receive the services they need in the current hospital 
setting. 
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 20, 2022, to July 
27, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like payment to be 
made to the hospital. The Plan denied your request. The Plan says that the clinical information provided does 
not substantiate the need for acute medical inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record shows that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from July 20, 2022, to July 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) 
replacement device. You asked the Plan to pre-approve a CPAP replacement device. You say that the machine does not properly 
function. The water tub pops off when the machine is running, and it needs to be rubber banded to stay in 
place. The seam for the tub is also deteriorated. Both issues cannot be resolved with repair. The Plan denied 
your request. The Plan says the records show that your current device is under five years old and the 
records do not show that your current CPAP is in disrepair or is unable to have parts replaced. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is determined through program instructions. 
 
We looked at the file and Medicare rules. The records show that the CPAP machine was issued on August 31, 
2017. The records do not show that the current device is in disrepair. The records also show that outreach was 
made to the vendor who noted that the enrollee needs a replacement water chamber. The vendor will have the 
parts department contact the enrollee to get the water chamber replaced and if not resolved, they will evaluate 
the current CPAP for repairs and/or replacement. Based on this information, we decided that Medicare rules for 
coverage of a CPAP replacement device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous positive airway pressure (CPAP) replacement device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says this 
enrollee has diabetes and is not on insulin. The Plan also says CGMs are not covered for an enrollee who is not 
on insulin. 
 
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 
FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate level of 
care for this enrollee, and they are medically stable to transfer to the LTACH at this time. The Plan denied your 
request. The Plan says based on Medicare guidelines, the LTACH services requested 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the Special Supplemental Benefits for the 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you feel the benefit would help the enrollee. 
The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefit have not been met. Specifically, we have confirmed that the enrollee does not 
require intensive care management. Therefore, we decided that the Plan does not have to pre-approve 
enrollment in the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enjaymo. 
 
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. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enjaymo was approved by the Food 
and Drug Administration (FDA) in February of 2022 as the first and only treatment indicated to decrease the 
need for red blood cell transfusion due to hemolysis in adults with cold agglutinin disease. The use of Enjaymo 
is not FDA-approved for the enrollee's diagnosis. It is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal. The services are therefore not safe and 
effective or reasonable and 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 Enjaymo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic rhizotomy (22102) and an unlisted 
procedure (64999) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve endoscopic rhizotomy and an unlisted procedure to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
endoscopic rhizotomy (22102) and an unlisted procedure (64999) to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880). 
 
You asked the Plan to pre-approve dental services. You say that you have temporomandibular joint disorder for 
20 years and your current appliance no longer fits. You disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the requested appliance is not covered by 
Medicare or your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal orthotic device (D7880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on April 15, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service is supported as billed. The Plan denied 
your request. The Plan says the use of code G0483 is not supported to accurately report the services provided. 
The record shows that only 20 drug classes have been tested in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug tests, definitive, 22 or more drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record shows that 20 
drug classes were tested, rather than 22 or more. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing (G0483) provided on April 15, 2022.