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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for myocardial infarction. Your medical problems are stable. There are 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the supplies and materials (99070) provided from April 30, 2021, to 
May 17, 2021. 
 
You asked the Plan to pay for the supplies and materials. You say that coverage for respite care after 
hospitalization is 100% for the first 20 days. You also say that the services should be covered. The Plan denied 
your request. The Plan says that the enrollee was enrolled in the hospice benefit on the dates of service in this 
case. 
 
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. Specifically, the file does not substantiate that the enrollee was under the hospice 
benefit during the dates of service in this case. We requested this information, but it was not received. Without 
this information we cannot confirm that the denial in this case was accurate. Therefore, we decided that the 
Plan has to pay for the supplies and materials (99070) provided from April 30, 2021, to May 17, 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on February 1, 2022. 
 
You asked the Plan to pay for the services provided. You say that the records justify the medical necessity of 
the service. The Plan denied your request. The Plan says the claim was billed with an inpatient only code. 
 
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 58575, an inpatient only code, was billed on an outpatient claim. CMS also does not 
pay for all other services on the same day as the inpatient only procedure. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the surgery services provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shower grab bars and iron railings 
 
You asked the Plan to pre-approve shower grab bars and iron railings. You say that this equipment to be 
installed in your home is necessary for your condition The Plan denied your request. The Plan says these items 
are statutorily non-covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve shower grab bars and iron railings
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge (99217) billed for June 10, 2021. 
 
You asked the Plan to pay for observation care discharge. You say that this service was billed correctly, as the 
enrollee was admitted to observation care the day before and was discharged from observation on the date in 
question. This service is separately payable. The Plan denied your request. The Plan says this service is not 
supported as billed, as there is no record of a claim for initial observation care on file for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there are no claims in the 
record which show that this same provider has billed for initial observation care (99218-99220) for this enrollee. Based on this information, we decided that Medicare rules for coverage of observation care discharge 
have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge 
(99217) billed for June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitoring services billed with codes 95927, 95937, 95939 
and 95938 for date of service February 10, 2022. 
 
You asked the Plan to pay for codes 95927, 95937, 95939 and 95938. You say that these services were reported 
correctly and are supported in the record. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that all items and non-physician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of 
whether they are subject to PPS.  We looked at the file and Medicare rules. The record shows that codes 95927, 95937, 95939 and 95938 were 
each billed with the TC modifier. The technical component of these codes is included in the payment to the 
facility. Therefore, separate payment may not be made. Based on this information, we decided that Medicare 
rules for coverage of codes 95927, 95937, 95939 and 95938 have not been met. Therefore, we decided that the 
Plan does not have to pay for monitoring services billed with codes 95927, 95937, 95939 and 95938 for date of 
service February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional continued physical therapy (PT) visits 
(97164). 
 
You asked the Plan to pre-approve additional PT visits. You say that you feel it is medically necessary for the 
enrollee to continue with therapy. The Plan denied your request. The Plan says there is no clinical evidence to 
support the medical necessity of this examination, or that the enrollee meets Medicare criteria for continued PT 
therapy services. 
 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 to pre-approve additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is generally accepted as a specific and effective 
therapy for the enrollee's condition of neck pain and cervicogenic headache. However, the documentation does 
indicate that there has been an improvement with therapy and in fact the enrollees cervical spine range of 
motion has decreased. Our reviewer also found that the records therefore do not demonstrate that the unique 
skills of a professional therapist are required to provide treatment safely and effectively. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 6 additional continued physical therapy (PT) visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve consultation services. You say that it is medically necessary for you to see 
this OON provider. The Plan denied your request. The Plan says there are multiple in-network options 
available for providers to treat your medical condition. 
 
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 
consultation services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee receives most of their daily calories 
from the enteral feeding. The Plan denied your request. The Plan says that the enrollee lives in a long-term care 
facility, and there were no therapy notes. The Plan also says the enrollee's care is more appropriate for long 
term care facility. 
 
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 
enrollee does meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does have 
documented skilled nursing needs. The enrollee has a new feeding tube in need of daily monitoring, 
maintenance and use. Our reviewer also found that daily skilled services are required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 your health is in severe danger of further 
deterioration without IRF care. The Plan denied your request. The Plan says your rehab needs can be met 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 surgical repair of a hip fracture after a fall. 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography, 
diagnostic, including image postprocessing; without contrast material (74261). 
 
You asked the Plan to pre-approve a CT colonography. You say that the CT scan is necessary. The Plan denied 
your request. The Plan says records show that the enrollee has no signs or symptoms related to his colon. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT colonography. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has anal skin tags, no 
abdominal pain, hematochezia, or difficulty defecating. He has not had a recent colonoscopy and refuses to 
have one now. A colonoscopy is considered standard of care for screening for colon cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic (CT) colonography, diagnostic, including image 
postprocessing; without contrast material (74261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that this device is necessary as 
you recently had knee surgery. The Plan denied your request. The Plan says the criteria for coverage have not 
been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that to qualify for coverage of a continuous passive 
motion device, use of the device must commence within 2 days following surgery 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that you had knee surgery 
on July 25, 2022. This device is being requested for use after the 2 days following surgery which Medicare 
rules state that must commence by. Based on this information, we decided that Medicare rules for coverage of a 
continuous passive motion device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. 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 non-surgical management of pelvic fractures and rotator cuff injury after a fall. Your medical problems are stable. There are 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. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided on December 21, 2021. 
 
You asked the Plan to pay for inpatient services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the services were not authorized. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. A prudent layperson would expect the need for immediate care for 
abdominal pain found to be due to acute cholecystitis where a surgeon has recommended immediate surgical 
removal. Therefore, no authorization can be required for this admission and surgery. Therefore, we decided that 
the Plan has to pay for inpatient services provided on December 21, 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.