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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a fall, rhabdomyolysis, and acute kidney injury. 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for hematuria and bladder stones. 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 a bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (93702). 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy. You say that services are medically 
necessary. The Plan denied your request. The Plan says the current role of bioimpedance spectroscopy remains 
uncertain. Based on review of existing evidence, there are currently no clinical indications for this technology. 
This service is considered experimental and investigational at present time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
bioimpedance spectroscopy at issue in this case meets all Medicare criteria for medically reasonable and 
necessary for the enrollee, per Social Security Act, Section 1862 (a)(1)(A). Provided medical records do not 
document that bioimpedance spectroscopy has been shown in controlled studies to consistently result in long 
term health benefits in enrollees with breast cancer; additional research is needed. 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 bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment (93702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 85025) provided on July 30, 
2021. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are requesting 
reconsideration of payment on this claim. The Plan denied your request. The Plan says this claim should not be 
separately reimbursed as the enrollee is covered under the skilled nursing facility (SNF) inpatient stay. 
 
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 80048 and 85025 is included in the Part A SNF payment. Specifically, the records show 
the enrollee was in a SNF from July 17, 2021, through August 5, 2021. The requested services had to be billed 
by the SNF to Part A. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(80048, 85025) provided on July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression 
procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee will be enrolled in an 
approved study. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression is only covered under certain medical indications.   
 
We looked at the file and Medicare rules. The file does not show that the enrollee is currently enrolled in an 
approved clinical study. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
percutaneous image-guided lumbar decompression procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular Nerve Block (64454, 64624). 
 
You asked the Plan to pre-approve a Genicular Nerve Block. You say that the services are medically necessary. 
The Plan denied your request. The Plan says Medicare does not cover experimental/investigational procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Genicular Nerve Block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks and of radiofrequency ablation is still under 
investigation and the procedures are considered experimental. 
 
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 Genicular Nerve Block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Genicular Nerve Block (64454, 64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair (K0001), elevating leg rests (K0195), 
armrests (E0973), and folding wheeled walker (E01743). 
 
You asked the Plan to pre-approve a wheelchair, elevating leg rests, armrests, and folding wheeled walker. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the member already 
has these items. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a wheelchair and walker. A wheelchair and walker serve the same purpose as a 
wheelchair, elevating leg rests, armrests, and folding wheeled walker. Therefore, we decided that the Plan does 
not have to pre-approve a wheelchair (K0001), elevating leg rests (K0195), armrests (E0973), and folding 
wheeled walker (E01743).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair push handles (K0108), pneumatic 
propulsion tire (E2211), and pneumatic propulsion tire push handles E2213), 
 
You asked the Plan to pre-approve the wheelchair push handles, pneumatic propulsion tire and insert. You say 
that the items are medically necessary. The Plan denied your request. The Plan says pneumatic tires are for 
outdoor use only and push handles are for caregiver convenience. 
 
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 the wheelchair push handles (K0108), pneumatic propulsion 
tire (E2211), and pneumatic propulsion tire push handles E2213),
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (CPT code 76642) provided on 
September 27, 2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. CPT code 76642 has an MUE value of 1 but 
billed 2 units. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound 
have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (CPT 
code 76642) provided on September 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
January 22, 2023, forward. . 
 
You asked the Plan to pre-approve continued SNF care. You say that continued SNF care is medically 
necessary. The Plan denied your request. The Plan says the clinical information provided supports therapy 
which can be provided at a lower level of care. 
 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 continued 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 the complexity of your nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from January 22, 2023, forward. .
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. You are receiving appropriate care at the present acute care hospital. There are no services available 
at the LTACH that you require that are not available at the health care setting being offered by the health plan. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis 
and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental and more research is needed to show its 
safety and efficacy. 
 
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 intracept procedure have not been met. 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve an intracept procedure (64628, 64629).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for cardiogenic shock, myocardial infarction, and 
congestive heart failure. 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for weakness and 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor. 
You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for coverage. 
 
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 transcatheter implantation of wireless 
pulmonary artery pressure sensor. Our reviewer says that there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
Our physician reviewer found at this time, the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees clinical management. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter implantation of wireless pulmonary artery pressure sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter implantation of 
wireless pulmonary artery pressure sensor (CardioMEMS) (33289).