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 stay is medically necessary. 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories 
(E0971, E0973, E2211, E2213, E2219, E2617, E2624, K0005, K0040, K0108) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that the enrollee is suffering without 
this chair and unable to live independently. You disagree with the denial and request approval for the requested 
items. The Plan denied your request. The Plan says the enrollee must receive services and items from an in-
network provider. Services are available in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ultralightweight wheelchair (K0005) and accessories (E0971, E0973, E2211, E2213, E2219, E2617, E2624, 
K0005, K0040, K0108) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (AFO), plastic or other material with 
ankle joint, prefabricated, includes fitting and adjustment provided on November 7, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the joint is unstable or that there is joint laxity. 
There is no indication that an AFO is required for stabilization for medical reasons or that there is a potential to 
benefit the member functionally. The requested AFO orthosis 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an ankle foot orthosis (AFO), plastic or other material with ankle joint, prefabricated, includes 
fitting and adjustment provided on November 7, 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 a lower level of care is not safe and efficient for the 
enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee's therapy could be 
done at 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the device is considered experimental and investigational. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve placement of a CardioMEMS device (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter aortic valve replacement 
(TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (33361). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is considered experimental and investigational. 
 
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 service. Our physician reviewer 
found while there have been several promising clinical studies, there remain calls for continued clinical trials to 
assess the efficacy of TAVR for aortic regurgitation. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, our physician reviewer would not 
consider TAVR to be medically necessary in this enrollee. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 
percutaneous femoral artery approach (33361).
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 will provide all the care the 
enrollee needs. LTACH services are the only option for a safe discharge at this time. The Plan denied your 
request. The Plan says they will continue to cover medically necessary acute and critical care at the current 
facility until the enrollee's condition is stable for transfer to an alternate level of care. 
 
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 in this case the enrollee was admitted for elective C3-5 laminectomy and C2-T3 
fusion and subsequently developed respiratory distress and cardiac arrest. The record indicates that the enrollee 
continues to have ongoing acute medical issues and still require acute 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99223) rendered on August 15, 
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 that Current Procedural Terminology (CPT) code 99223 remains not supported. 
 
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 99223 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit." 
 
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 supported by the medical records. Our reviewer found that the patient was noted to have 
pneumonia with hypoxia, in the setting of chronic lymphocytic leukemia (CLL) and prior pre-vaccination 
CoViD-19. There was debate as to whether her pneumonia was bacterial, atypical or hypersensitive. As such, 
her care required a pulmonology consult and more detailed monitoring.  The documentation does contain a 
comprehensive history, comprehensive examination and high-complexity medical decision making. As such, 
the billing of CPT 99223 is supported. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
initial hospital care (procedure code 99223) rendered on August 15, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have provided medical records to support SNF 
care. The Plan denied your request. The Plan says SNF services are 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that at the time of discharge from the hospital the member had stabilized 
medically.  The member did not require any skilled nursing or rehab services on a daily basis at an inpatient 
level of care.  She was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or self-care tasks.  The member did not 
require skilled therapy to establish a safe and effective maintenance program.  As a practical matter, the 
member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of 
discharge from the hospital. The member did not have any parental medications, complex wound care or 
nutrition given via a feeding tube.  She was medically stable without any acute exacerbations of chronic 
medical problems.  Her physical function was at or near her baseline and she could have received further 
services at a lower level of care. Admission to the nursing facility at a skilled level of care for inpatient skilled 
services was 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee need this ventilator in order to 
live. This is a urgent request. The enrollee cannot leave the hospital until this is approved. The Plan denied 
your request. The Plan says the requested device is not being used as a ventilator with set full tidal volume 
delivery. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in volume targeted pressure support mode (which is 
equivalent to average volume assured pressure support (AVAPS) mode) which could be provided by a BiPAP 
device with AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for 
ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
kit sensor. 
 
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 criteria for coverage are not met. 
 
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 treat with 
insulin three or more times per day or use an insulin pump. 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 a Freestyle Libre 2 continuous glucose monitor (CGM) kit sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
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 treat with 
insulin three or more times per day or use an insulin pump. 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 a Dexcom G6 continuous glucose monitor (CGM).
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 the enrollee requires oxygen which 
requires them to be in an acute level of care. The enrollee wants to be able to recover and you feel that it is 
possible that they can recover with the proper level of care. The Plan denied your request. The Plan says the 
enrollee can safely receive this care 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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The health 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Xofigo (radium Ra 223 dichloride) injection. 
 
You asked the Plan to pre-approve a Xofigo (radium Ra 223 dichloride) injection. You say that a Xofigo 
(radium Ra 223 dichloride) injection is medically necessary. The Plan denied your request. The Plan says the 
Xofigo (radium Ra 223 dichloride) injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Xofigo (radium Ra 223 dichloride) 
injection. Our reviewer says that the requested Xofigo (radium Ra 223 dichloride) injection is not considered 
medically reasonable and necessary in this case. Our physician reviewer found Xofigo is Food and Drug 
Administration (FDA) approved for the treatment of castration-resistant prostate cancer in patients with 
symptomatic bone metastases and no known visceral metastatic disease. However, the health Plan requires that the enrollee have a hemoglobin of 9 or greater, which the enrollee does not have. The requested service 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 a Xofigo (radium Ra 223 dichloride) injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Xofigo (radium Ra 223 dichloride) injection.