Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request is 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 you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to provide additional payment for a wig (A9282) provided on November 7, 2022. 
 
You asked the Plan to provide additional payment for a wig. You say that you do not understand why the claim 
was not approved for the full benefit amount. The Plan denied your request. The Plan says that this claim 
processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Medicare does not pay for wigs. However, the Plan offers a benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
wigs up to 100% of the approved amount until the $300 lifetime limit is met. 
 
We looked at the file and Medicare rules. We did not see where the contract says that each wig will only be 
covered up to $200. The Plan contract does not clearly say that the full $300 limit would not apply to the cost 
of a wig. Therefore, we decided that the Plan has to provide additional payment for a wig (A9282) provided on 
November 7, 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: 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 you need IRF services after your hip fracture so you 
can regain maximum function. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is not supported by the research and not covered. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered to be an experimental/ investigational procedure because of the wide variation in 
efficacy reported in the literature. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation to the sacroiliac joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the Medicare criteria and will 
benefit from IRF services that cannot be accomplished at a lower level. The Plan denied your request. The Plan 
says the requested IRF services are 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric wheelchair. 
 
You asked the Plan to pre-approve the electric wheelchair. You say that the requested wheelchair is medically 
necessary. The Plan denied your request. The Plan says that no valid standard written order or valid face-to-
face visit documentation was provided. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The record shows that the face-to-face visit performed on February 23, 2023, does not include documentation 
on your ability to perform activities of daily living. This means that Medicare rules for coverage of a PMD 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that a continuing stay is 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage because 
there is another setting for treatment of these problems. His needs can still be met in an outpatient setting with 
services and support. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 continued inpatient psychiatric care. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on February 3, 2023, with bipolar disorder type I, 
severe, current episode manic with psychotic features. Based upon review, the records provided it was not 
expected this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and does not have auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis beyond the date in question. The reviewer is unable to find 
an individualized treatment plan however, the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review, the records provided for the admission of this 
enrollee does not meet the criteria for March 13, 2023, forward as this enrollee was not shown to be a danger to 
herself or others, delusions, auditory or visual hallucinations noted. She was cooperative/compliant with 
treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97530) provided on April 13, 2022. 
 
You asked the Plan to pay for therapy services. You say that that this claim has been filled out correctly. The 
Plan denied your request. The Plan says the taxonomy code reported for this provider does not match the 
taxonomy code on file with the Centers for Medicare and Medicaid Services for the provider with this NPI. 
 
The Plan must follow Medicare rules. Medicare rules say that the rendering provider's National Provider 
Identifier (NPI) should be entered in the lower unshaded portion of item 24J.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the taxonomy code reported with this NPI does 
not match the taxonomy code on file with the National Plan and Provider Enumeration System (NPPES) for 
this provider. The taxonomy code reported is for a facility. Therefore, we decided that the Plan does not have to 
pay for therapy services (97110, 97530) provided on April 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophageal balloon distension study and breath test. 
 
You asked the Plan to pre-approve an esophageal balloon distension study and breath test. You say that an 
esophageal balloon distension study and breath test is medically necessary. The Plan denied your request. The 
Plan says an esophageal balloon distension study and breath test does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare 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 pre-approve an esophageal balloon distension study 
and breath test. Our reviewer says that an esophageal balloon distension study and breath test is not medically 
necessary in this case. Our physician reviewer found over the four years of gastrointestinal (GI) related studies, 
the following objective findings have been made: esophagitis, post-myotomy for achalasia, acuate ligament 
syndrome with resulting critical stenosis of the celiac axis, early changes of pancreatitis and pancreatic 
insufficiency, gallbladder polyp. Given the multitude of objective GI findings that may contribute to your 
reported symptoms and at your age, irritable bowel syndrome (IBS) is an unlikely diagnosis. In addition, no 
data as was provided supported a small bowel motility disorder nor of partial obstruction to increase the 
likelihood of small intestinal bacterial overgrowth (SIBO). Nevertheless, to allay your concerns for SIBO, an 
empiric trial of Xifaxan would be commonly used at this juncture and seen by most gastroenterologists as a 
reasonable next step. Formal breath testing is neither medically appropriate nor necessary at this time and 
would not be expected to change your management from an empiric Xifaxan course. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an esophageal balloon distension study and breath test have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an esophageal balloon distension study and 
breath test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pigmented lesion assay (PLA) (0089U) provided April 8, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that the test was ordered by an in-network 
physician who felt it was medically necessary to evaluate and determine effective treatment planning to the 
enrollee. The Plan denied your request. The Plan says additional information is needed to consider this charge. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a skin lesion and DermTech PLA (molecular pathology) testing was 
performed. This new test uses genomics testing using an adhesive patch. However, current literature does not sufficiently support this method over standard testing/screening biopsies. The was no found high quality study 
finding this testing method superior in terms of overall morbidity or mortality to justify its regular use in 
similar cases. Therefore, this request for this testing will be considered not medically necessary at this time. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the pigmented lesion assay (PLA) (0089U) provided April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ambulatory surgical boot. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve an ambulatory surgical boot.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 29, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Avise CTD test (0312U) provided June 6, 2022. 
 
You asked the Plan to pay for the Avise CTD test. You say that based on the enrollee's specific clinical 
diagnosis, the enrollee's physician ordered the Avise CTD test. The Plan denied your request. The Plan says 
this service does not meet the coverage requirements. 
 
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 Avise CTD test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has myalgia and fatigue. Their physician ordered the Avise connective tissue 
disease (CTD) test, a test that combines multiple serological markers to help differentiate systemic lupus 
erythematosus (SLE) with other diseases. This test is estimated to be 80% sensitive for SLE and 86% specific for SLE. However, when considering treatment for a connective tissue disorder, accuracy is less important than 
signs of organ or other tissue damage, which can be monitored using simple blood tests or imaging. If CTD is 
already on the differential, treatment should be considered anyway regardless as all autoimmune disease is 
treated similarly. Current evidence supports perhaps better accuracy using Avise CTD for SLE, however, it is 
not clear from current high-quality literature, if using this test leads to overall improved major outcomes 
(mortality, morbidity) in those tested compared to standard testing methods to support this request. Therefore, 
without sufficient support made for this request, the Avise CTD will be considered 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 Avise CTD test have not been met. Therefore, we decided that the Plan does 
not have to pay for the Avise CTD test (0312U) provided June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close physician oversight and 
occupational therapy to increase their strength and endurance to return home safely. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at an 
alternate 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.