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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion interspinous spacer. You say that you have severe pain that is 
impacting your quality of life and ability to function. You say that the pain and swelling makes it very difficult 
to walk, and you've lost weight. The Plan denied your request. The Plan says the use of this device for long 
term relief of back and leg pain is not supported. The Plan say that there are no clinical indications for this 
technology. 
 
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 Superion interspinous spacer. Our 
reviewer says that the Superion interspinous spacer is not considered medically reasonable and necessary in 
this case. Our physician reviewer found this device is experimental and more 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 the Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency endotracheal intubation (31500) provided on 
October 4, 2020. 
 
You asked the Plan to pay for an emergency endotracheal intubation. You say that the claim was not filed 
timely due to delays related to the COVID-19 public health emergency. The Plan denied your request. The Plan 
says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an emergency endotracheal intubation was not filed until February 10, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency endotracheal intubation (31500) 
provided on October 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no 
documentation of ongoing medical management requiring skilled nursing oversight. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found that the enrollee does not have documented skilled nursing needs. As such, the requested, ongoing home 
health services are not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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. The Plan denied your request. The Plan says the enrollee does not 
need an intensive program with a team of professionals. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for shortness of breath and parainfluenza infection. Medical 
problems are stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided on February 7 to February 8, 2022. 
 
You asked the Plan to pay for inpatient services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan indicates that the inpatient services at issue were not authorized; 
however, the case record contains an approval letter for inpatient services. It is the Plan's responsibility to 
substantiate its denial. In this case, the denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for inpatient services provided on February 7 to February 8, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99211, 99072) provided September 9, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says insufficient information was provided to support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. No clinical records were provided to support the claim. Based on this 
information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of physician services (99211, 99072) provided September 9, 2021. have been met. Therefore, we 
decided that the Plan does not have to pay for physician services (99211, 99072) provided September 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00532) provided on August 6, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the anesthesia services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan indicates that coverage criteria in the applicable Local or National 
Coverage Determination have not been met; however, the applicable rule has not been identified. It is the Plan's 
responsibility to substantiate its denial. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for anesthesia services (00532) provided on August 
6, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services coded as G0299, G0300, Q5001, 
G0151 and G0152 provided December 1, 2020 to December 29, 2020. 
 
You asked the Plan to pay for the home health services. You say that please see attached documents to show all 
Medicare guidelines were followed. The Plan denied your request. The Plan says this provider has not 
submitted any clinical records to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services coded as 
G0299, G0300, Q5001, G0151 and G0152. have been met. The records show that the Plan made several 
attempts to obtain medical records from the provider without success. Therefore, we decided that the Plan does 
not have to pay for the home health services coded as G0299, G0300, Q5001, G0151 and G0152 provided 
December 1, 2020 to December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sling operation for stress incontinence (eg, fascia or 
synthetic) (CPT code 57288). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they had a demonstration of stress 
incontinence or an assessment of urethral mobility. 
 
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 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's records do not show evidence of genuine stress incontinence and urethral 
mobility. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sling operation for stress incontinence (eg, fascia or synthetic) (CPT code 57288).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on March 31, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on March 31, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan of lower extremity arteries or arterial bypass grafts 
(93926) provided on January 20, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says that the criteria for this service 
are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear argument or any specific 
citation/evidence to show why this claim should be denied. Therefore, we decided that the Plan has to pay for 
the duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided on January 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies (CPT code(s): K0553 and 
K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documents do not show the enrollee needs to check their blood 
sugar level at least 4 times a day, that they are currently using the medicine insulin 3 or more times a day, and 
the notes do not show if the enrollee has been seen recently for their condition (within the past 6 months). Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies (CPT code(s): 
K0553 and K0554).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enrollee has multiple exams on the date of service 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date 
of service. Please reconsider for processing. The Plan denied your request. The Plan says this procedure 
exceeds the maximum number of services allowed under the Plan's guidelines for a single date of service 
 
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, the CPT Code Manual definition of code 76642 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited.  
We find that CPT code 76642 is not supported in the medical record. Specifically, the records do not support 
that this test was provided multiple times on the same day. The records provided shows the same test with the 
same time. The records show that the Plan had paid for this service on check dated 2/22/2022. Based on this 
information, we decided that Medicare rules for coverage of the diagnostic service have not been met. 
Therefore, we decided that the Plan does not have to pay for the enrollee has multiple exams on the date of 
service
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 had a hip replacement and rehabilitation 
is needed for a full recovery. The Plan denied your request. The Plan says based upon the enrollee's current 
level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily 
therapy. 
 
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 surgical management of non-union of a femur 
fracture. Medical problems are stable. Our physician reviewer found there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. Medically necessary care can be provided in a different level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you do need physical and/or 
occupational therapy, there is no documentation of a need for and ability to tolerate an intensive rehabilitation 
program. 
 
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.