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

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found evaluating therapists all recommend ongoing therapy in an IRF setting thus IRF criteria met.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 pay for inpatient hospital services provided on January 21, 2022 to 
January 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 sepsis, unspecified organism (A41.9). 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 this diagnosis is not supported in the medical record. Our physician reviewer found 
there was no laboratory or clinical evidence of sepsis. The review has determined that the documentation did 
not support sepsis, unspecified organism (A41.9).  
 
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 21, 2022 to January 28, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
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 sacral nerve stimulation 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 records do not show that the 
enrollee is refractory to conventional therapy. The records show she has stress incontinence and neurologic 
disease from a brain tumor. The records do not show that the enrollee is able to demonstrate adequate ability to 
record voiding diary data such that clinical results of the implant procedure can be properly evaluated. 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 sacral nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on May 9, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
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 that CPT code J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of another code billed for the same date of service. Based on this information, we 
decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code J3490 provided on May 9, 2022.
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 to help you regain your 
prior level of function. The Plan denied your request. The Plan says the services you need can be provided 
safely in another setting such as a skilled nursing facility. 
 
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 while you may benefit from physical and occupational therapy, your needs can be met in a lower intensity and alternate setting, such as a skilled nursing. You do not need intensive therapies 
consisting of at least three hours of therapy per day, at least five days per week, with a multidisciplinary 
approach. You are medically stable with no acute nursing needs identified. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 31, 2022 to 
August 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 31, 2022 to August 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of prostate tissue using radiofrequency 
induced heated water vapor (53854). 
 You asked the Plan to pre-approve the water vapor treatment. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one treatment for lower urinary tract symptoms 
attributable to benign prostatic hyperplasia (LUTS/BPH) treatment is covered once in patients who meet the 
criteria. 
 
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 water vapor treatment. Our reviewer 
says that this service is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has prostate cancer and a prostate specific antigen of 13. Therefore, the reviewer 
found that the requested service 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 the water vapor treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve destruction of prostate tissue using radiofrequency induced heated water 
vapor (53854).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization for treatment of knee 
osteoarthritis (37242, 36247, 36248, 37243, 75710, 76937). 
 
You asked the Plan to pre-approve geniculate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 geniculate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. While the studies are 
noted to be promising, further studies/research is needed to corroborate that geniculate artery embolization is as 
good as or better than standard treatments for knee osteoarthritis. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested geniculate artery embolization, 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 geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve geniculate artery embolization for treatment of knee osteoarthritis 
(37242, 36247, 36248, 37243, 75710, 76937).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require intensive rehabilitation services. 
 
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 Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the enrollee has longstanding Type 2 
Diabetes with significant end-organ disease, including severe diabetic peripheral neuropathy and 
atherosclerotic disease. You also say that in the long run, this should save the insurance plan a substantial 
amount of money. The Plan denied your request. The Plan says the prior authorization criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Dexcom G6 sensor have been met. 
Medical records were not provided with this case. The Plan made multiple requests for this information, but it 
was not received. Without medical records we are unable to determine if the enrollee meets the criteria for 
coverage for the Dexcom G6 sensor. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (codes 64483, 64484, 
77003, J1030). 
 
You asked the Plan to pre-approve the repeat epidural steroid injections. You say that you do not understand 
what information is missing or needed for this enrollee to be approved. The Plan denied your request. The Plan 
says the enrollee's last epidural steroid injection was December 07, 2022. The Plan also says this request is for 
the same site done on December 07, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function for at least 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 the repeat epidural steroid injections. 
Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the 
LCD requires 50% pain relief for 3 months. Our reviewer found that this was not achieved and therefore, the 
request is deemed not medically reasonable and 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 repeat epidural steroid injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat epidural steroid injections (codes 64483, 64484, 77003, 
J1030).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require intensive activities of daily living training. You do not require 
frequent physiatry oversight. 
 
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: Favorable

 
We decided that the Plan has to pay for anesthesiology services (00830) provided on February 9, 2022. 
 
You asked the Plan to pay for the anesthesiology services. You say that this service was medically necessary 
and rendered by an anesthesia provider. The Plan denied your request. The Plan says that anesthesia codes are 
only payable when billed by an anesthesia provider. 
 
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 records provided show this service was provided by an anesthesia provider. 
The plan did not provide a copy of the claim for review. Therefore, we decided that the Plan has to pay for 
anesthesiology services (00830) provided on February 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional home skilled nursing visits. 
 
You asked the Plan to pre-approve two additional home skilled nursing visits. The Plan denied your request. 
The Plan says you need help at home, but the help does not require the knowledge, judgement, and skills of a 
skilled nurse. The Plan also says you do not have skilled needs. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 two additional home skilled nursing 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found you do not require additional skilled nursing services to effectively provide treatment, care, and/or 
services in order to improve your condition, perform a maintenance program to maintain your condition and/or 
prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two additional home skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve two additional home skilled nursing visits.
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 for you to get the 
rehabilitation needed. The Plan denied your request. The Plan says care could be received in another 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 you are medically stable with no acute illness. You do not require close physician 
supervision three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. You do not require three hours a day/five days a week of therapy with a multidisciplinary approach in the IRF. 
Needs can be safely provided for in an alternate and low intensity setting, such as in-home with services or in a 
skilled nursing 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 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.