Persius/hicric huggingface dataset:
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 LTACH care is medically necessary as 
the patient has been in the hospital since October 26, 2022. The Plan denied your request. The Plan says 
LTACH is not medically necessary because the patient is receiving appropriate care at the current facility. 
 
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 was admitted with acute on chronic hypoxic respiratory failure in the 
setting congestive heart failure exacerbation. The record indicates that the enrollee is improved and is indicated 
for discharge from the acute care setting. The enrollee continues to receive acute care services, and these have 
not been denied.  The medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that going to an acute inpatient rehabilitation facility 
would offer the enrollee the best chance of improving and returning to their baseline. The Plan denied your 
request. The Plan says that the 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 that the documentation does not support the medical necessity for admission to an 
IRF due to lack of medical complexity, and high functional level with no nursing needs. While the enrollee would benefit from physical and occupational therapy the enrollee's rehabilitation needs can be safely provided 
in an alternate and low intensity setting such as 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 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the patient does not meet 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. Their medical problems are stable and there are no complex nursing or rehabilitation 
needs. The patient 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 patient 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: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says LTACH care is not medically necessary as continued 
acute hospital care is appropriate. 
 
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 was admitted with headache and found to have subarachnoid hemorrhage 
and intraventricular bleeds with hydrocephalus. The record indicates that the enrollee remains critically ill with 
tachypnea fever, and coma and still requires acute critical care services. The enrollee continues to receive acute 
care services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
pneumatic appliance, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the device is 
medically necessary. The Plan denied your request. The Plan says there is no evidence to support lymphedema 
extended to the chest, trunk, or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a pneumatic appliance, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00811, 99100) provided 
to the enrollee on May 25, 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 until a corrected claim with updated modifiers is received, this has denied correctly and will be 
upheld. 
 
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 the denied codes is:  
CPT 00811: 
 
Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise 
specified 
 
CPT 99100: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
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 in this case, modifier -53 
(discontinued procedure) would be applicable if anesthesia was administered and the procedure was terminated 
due to extenuating circumstances, such as discontinuation due to a poor colonoscopy prep, however, was not 
used. Therefore, the submitted anesthesiology CPT code 00811-52 is not supported in this case. 
 
Additionally, CPT 99100 has a status indicator of B on the Physician Fee Schedule. This means that the 
procedure cannot be paid separately. 
 
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 anesthesia services (procedure code 00811, 99100) provided to the enrollee on May 25, 2022.
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 needs dialysis. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can get 
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 the enrollee is more stable and improving and should only require short-term 
additional acute care services that can safely be performed at the current facility. Transfer to the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve three sessions. We decided that the Plan does not have to pre-
approve the other seven sessions.  
 
You asked the Plan to pre-approve ten additional physical therapy sessions.. You say that these services are 
medically necessary. The Plan says that the enrollee has already had 30 physical therapy sessions. 
 
We decided that the Plan has to pre-approve three sessions.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for the visits. Our reviewer says that an additional 
three requested therapy sessions are generally accepted as specific and effective therapy for the patients 
condition. A remaining three sessions are reasonable to ensure proper review of a home exercise program with 
the patient and caregiver. 
 
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 sessions have been met. Therefore, we decided that the Plan has to pre-
approve three sessions.  
 
We also decided that the Plan does not have to pre-approve the other seven sessions. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for the other visits. Our reviewer says that seven of the 
requested ten therapy visits are not medically necessary. The patient has had prior extensive therapy and the 
documentation does not reveal that the patient requires seven of the ten therapy visits with the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance 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 the other seven sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the other seven sessions. 
 
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 since being in the hospital, you have lost mobility. 
You require intense therapy to regain strength and mobility so that you can live at home. The Plan denied your 
request. The Plan says you do not meet IRF criteria and can be managed at a lower level of 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
Clostridium difficile colitis. Your medical problems are stable and you have no complex nursing or 
rehabilitation needs. You do 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 you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
request for coverage for admission to a long term acute care hospital is 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted on October 23, 2022 for pneumonia. The enrollee's hospital 
stay was complicated by sepsis, hypotension requiring pressors, hyponatremia, hyperphosphatemia, 
hypomagnesemia, acute encephalopathy, acute on chronic hypoxic respiratory failure and acute kidney injury. 
The enrollee is not required for discharge elsewhere to receive ongoing acute level care. The enrollee requires 
daily physician visits, telemetry, intravenous medications, high flow oxygen, physical, occupational and speech 
therapy. The enrollee is receiving appropriate care at the present setting. The enrollee does not require services 
at the LTACH that are not available at the acute care hospital where they are 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 the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 9 additional home health PT visits. You say that these additional visits are 
medically necessary. The Plan denied your request. The Plan says additional home health PT visits are not 
medically necessary. 
 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 9 additional home health PT visits. Our 
reviewer says that the additional home health PT visits are not medically necessary. Our physician reviewer 
found the enrollee does not have documented, ongoing, home health PT needs.  The enrollee is independently 
mobile.  As such, the requested, ongoing, home health PT services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 additional home health physical therapy (PT) visits.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing (G0483) provided October 5, 2021. 
 
You asked the Plan to pay for the drug testing. You say that please review the presumptive vs prescriptions and 
based on the conditions, it does meet approval of definitive testing at the level. The Plan denied your request. 
The Plan says that Under Medicare rules, the request for definitive urine drug testing of this number of drug 
classes is considered not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the drug testing. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is on long term opiate therapy for pain. The enrollee had markedly abnormal 
testing and definitive testing was indicated. A urine toxicology detected THC, Nicotine and Hydrocodone 
which were not prescribed and the absence of Hydromorphone which was prescribed. 
 
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 drug testing have been met. Therefore, we decided that the Plan has to pay 
for the definitive drug testing (G0483) provided October 5, 2021.  
 
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.