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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with altered mental status and 
acute respiratory failure following a fall. The enrollee required mechanical ventilation support, cervical fusion 
surgery, trach placement, percutaneous endoscopic gastrostomy placement later changed to G-tube, and 
complicated by anemia requiring a blood transfusion. Recent notes describe the enrollee as now tolerating trach 
collar during the day and tolerating tube feeds. The enrollee appears to be more stable and improving and 
should only require short term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a injection (20610). 
 
You asked the Plan to pre-approve an injection. You say that the enrollee has mobility issues due to the pain in 
their knees. You say that the enrollee needs these injections. You also say that they have had them in the past 
and have helped. The Plan denied your request. The Plan says the injection is not medically necessary. 
 
Plan follows Medicare rules. Medicare rules say that purified natural hyaluronates have been approved by the 
FDA for the treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond to 
simple analgesics or conservative nonpharmacologic 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 an injection. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found the provided documentation does 
not support that the enrollee has tried conservative therapy, including physical therapy (PT), a home exercise 
program, analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, the reviewer found that the 
requested injection 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 an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a injection (20610).
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital for abdominal pain. The member was 
determined to have a perforated intestine from diverticulitis with sepsis. There is no documentation provided 
indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the 
present acute care hospital. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs wound care to skin graft site, has 
elevated blood pressure, and requires iron and blood transfusions due to low hemoglobin. The Plan denied your 
request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee can safely receive the services needed 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. Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The enrollee can receive further services at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress. 
 
You asked the Plan to pre-approve a hospital bed, semi-electric. You say that due to various medical 
conditions, you need the bed to be able to raise your legs up and change your head/body positions frequently 
due to chronic and extreme pain. This would also greatly reduce your quality of life and cause unnecessary 
pain/suffering if you are without the bed. The Plan denied your request. The Plan says you do not meet criteria 
for the requested hospital bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed, semi-electric. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not have 
congestive heart failure or COPD. You do not require positioning unavailable with a standard bed and are not 
dependent for positioning. You do not meet criteria for the requested bed. 
 
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 hospital bed, semi-electric have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), with any type of 
side rails, with mattress.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 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, we have confirmed that code 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 30, 2022.
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 that the enrollee requires a critical illness 
recovery hospital for daily physician oversight. You say that the enrollee is medically stable to be transferred to 
LTACH level of care at this time. The Plan denied your request. The Plan says an LTACH 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds K0823. 
 
You asked the Plan to pre-approve the group 2 power wheelchair. You say that you are in need of the power 
chair because you have no way of getting around without a chair. You had two strokes and is limited in the 
ability to push a chair manually. The Plan denied your request. The Plan says the records do not support 
medical necessity of the requested power wheelchair. 
 
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.  
 
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 group 2 power wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found A clinical progress note dated 7 27 2022 indicated that the patient was 
evaluated for her annual wellness visit and that she uses a manual wheelchair for mobility. No documentation 
is provided in terms of a mobility and home assessment, including the patients current level of mobility and 
function, physical examination findings and if the patients home is accessible for the requested group 2 power 
wheelchair. It is not possible to determine if the requested group 2 power wheelchair is appropriate and 
necessary without this information. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair, group 2 standard, captains chair, patient weight capacity 
up to and including 300 pounds K0823.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service February 4, 
2022. 
 
You asked the Plan to pay for procedure code 97110. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526.  
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, we have confirmed that code 97110 
is a column II code to column I code 92526. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 97110 billed for date of service February 4, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 7, 2021, to 
February 12, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
billed correctly. The Plan denied your request. The Plan says the billed DRG and primary diagnosis are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, sepsis, unspecified 
organism, and DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with 
major complications or comorbidities. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the original DRG is not 
supported. Our physician reviewer found severe sepsis is defined as sepsis complicated by organ dysfunction. 
In this case, there is no clinical or laboratory evidence of sepsis. The enrollee remained hemodynamically 
stable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 7, 2021, to February 12, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral breast implant revision and augmentation. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee previously had breast 
implants. The record does not indicate the presence of silicone implant rupture or painful contractures. The 
record indicates a desire to increase breast size. The record provided does not establish the medical necessity 
and reasonableness of the requested procedures. 
 
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 bilateral breast implant revision and augmentation.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the placement of a LINX Reflux Management System (43284). 
 
You asked the Plan to pre-approve the placement of a LINX Reflux Management System. You say that this is 
medically necessary. The Plan denied your request. The Plan says that this has not been proven safe and 
effective for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the placement of a LINX Reflux 
Management System. Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found LINX is a standard surgical treatment for 
gastroesophageal reflux disease (GERD) in patients who are refractory to medication or choose to avoid 
medication use. The records show that you have GERD without any conditions that would exclude to the 
procedure. The requested procedure is an accepted standard treatment for GERD which has been shown in 
published studies to be safe, effective and durable 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 placement of a LINX Reflux Management System have been met. 
Therefore, we decided that the Plan has to pre-approve the placement of a LINX Reflux Management System 
(43284).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 28, 2022, to May 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the individual provider was participating with the 
Plan. The Plan denied your request. The Plan says enrollees must receive care from a network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from April 28, 2022, to 
May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that the requested drug is necessary for the enrollee. You 
also say that you need the enrollee's hemoglobin to be higher before their surgery. The Plan denied your 
request. The Plan says the enrollee has not tried and failed one of the preferred drugs, Retacrit or Procrit. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Epogen. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed one of the preferred drugs. The reviewer found that there is no indication 
that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
The reviewer also found that the provided records do not document the enrollee has adequate iron stores as 
required for accepted use of Epogen. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.