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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 26, 2021, to 
August 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary 
for this enrollee on the dates in question. The Plan denied your request. The Plan says that the criteria for 
medical necessity were not met for this inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department on August 26, 2021, with fever, 
diarrhea and headache. She reported shortness of breath for two weeks and was admitted for pneumonia. 
During the admission she was monitored by Pulmonary and treated with Levofloxacin, Zosyn intravenous and 
Sertraline. Her condition stabilized and improved, and she was discharged home when considered medically 
stable on August 30, 2021. The review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 26, 2021, to August 30, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services provided on 
January 10, 2022, were medically necessary. The Plan denied your request. The Plan says the ambulance 
services provided on January 10, 2022, were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services provided on January 10, 2022, were not medically necessary. Our physician 
reviewer found the reviewed documentation indicates that at the time of ambulance transport the enrollee was 
medically stable and ambulatory. She was able to sit in a chair or wheelchair. The review has determined that 
the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this enrollee on January 10, 2022. The 
documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully equipped ambulance can provide for safe transport on January 10, 2022. The 
documentation did not support that the ambulance transport on January 10, 2022, was medically reasonable or 
necessary for the 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on January 10, 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 this is medically necessary. The Plan denied your 
request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hospital after a mechanical fall without head trauma 
or loss consciousness or focal neurological deficit. The patient was noted to have evidence of a urinary tract infection and treated with antibiotics. She was noted to be in atrial fibrillation upon admission and rate control 
was achieved with medication. The patient was noted to have hyponatremia and this stabilized during the 
course of hospitalization. The patient does not have the medical complexity to require interdisciplinary 
rehabilitation and a rehabilitation for management of her medical issues. She also has no wounds and does not 
require rehabilitation nursing. The patient participated in therapy but was limited by anxiety and fear of falling.  
The patient requires minimum assistance for upper body tasks and more assistance for lower body tasks. The 
patient requires therapy, but not at the intensity of acute inpatient rehabilitation and it is not clear if she can 
tolerate or benefit from this level of physical and occupational therapy. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for psychology services performed by a clinical psychologist 
provided on January 25, 2022. 
 
You asked the Plan to pay for psychology services performed by a clinical psychologist. You say that the 
services were necessary. The Plan denied your request. The Plan says the documentation does not support 
contact with the attending or primary care physician. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that unless the beneficiary's primary care or attending 
physician has referred the beneficiary to the clinical psychologist, to inform the beneficiary that it is desirable 
for the clinical psychologist to consult with the beneficiary's attending or primary care physician (if the 
beneficiary has such a physician) to consider any conditions contributing to the beneficiary's symptoms.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychology services performed by a clinical psychologist have not been met. Therefore, we 
decided that the Plan does not have to pay for psychology services performed by a clinical psychologist 
provided on January 25, 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 IRF care is medically necessary so that you can get 
some rehab to gain strength back in your left arm and left leg. The Plan denied your request. The Plan says 
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. 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 a stroke and were discharged home on May 16, 2022. You have had weakness and multiple falls since discharge. 
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 tyou have a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a femoral revascularization procedure 
performed on July 9, 2021. 
 
You asked the Plan to waive the copayment for the revascularization. You say that you did not receive a bill 
until March 2022. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for outpatient procedures or services.  
 
You have been asked to pay a $250 copayment for the revascularization. The revascularization falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan.  
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a femoral revascularization procedure 
performed on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says your breathing needs can be met with a BIPAP machine that is not a portable 
ventilator. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found it is not 
documented that bilateral positive airway pressure (BiPAP) with a back-up rate or volume-assured pressure 
support have been utilized and failed. Products classified as E0466 when used to provide CPAP or bi-level 
PAP shall not be paid in the FSS payment category, regardless of the underlying medical 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional twelve physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that not having access to the amount of physical therapy 
being requested will result in further health issues in the future. The Plan denied your request. The Plan says 
that the additional number of visits requested are not medically necessary or reasonable. 
 
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 the visits. Our reviewer says that the 
requested additional visits are medically reasonable and necessary. Our physician reviewer found that per the 
clinical documentation, you still have significant range of motion deficits and weakness, in which 16 total visits 
would be medically reasonable for diagnosis purposes. With these documented findings, you would continue to 
require a professional therapist for treatment. 
 
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 visits have been met. Therefore, we decided that the Plan has to pre-approve 
an additional twelve physical therapy visits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
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 an ESI 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 enrollee has a history of neck pain 
that radiates to the left shoulder after a fall on September 29, 2021. He had a C7 to T1 ESI on December 28, 
2021 but there is no documentation of a response to this injection. Without this documentation, the criteria for 
coverage are not met and the repeat ESI 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
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 you are unable to walk and need more intense rehab. 
The Plan denied your request. The Plan says 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. 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 a 
urinary tract infection about 6 months in the past and are currently living in a nursing facility. 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 you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the the enrollee does not meet criteria for coverage of an IRF admission. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee 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 enrollee 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 additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that these items are needed and overwhelmingly 
supported. The Plan denied your request. The Plan says the three items in dispute are 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical documentation to support an expandable controller system represented by 
code E2377, an electronic connection represented by code E2311, and a harness represented by code E2313 as 
being medically necessary. The documentation states why upgraded electronics through the joystick can be 
helpful but nothing to support this specific clinical case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
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 this is medically necessary. The Plan denied your 
request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis and urinary tract infection. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. The enrollee 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 enrollee 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.