Persius/hicric huggingface dataset:
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 you are in the hospital and unable to get out of bed 
and this will jeopardize your ability to regain maximum function. The Plan denied your request. The Plan says 
the request is not medically necessary, you can safely receive the services you need in other settings, for 
example: a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array. You say 
that the requested service is medically necessary. The Plan denied your request. The Plan says the provider is 
requesting Sprint PNS trial for chronic pain. As the Sprint PNS device request is not for a trial for a 
permanently implanted device and as the Sprint PNS electrodes/battery are neither permanent nor surgically 
implanted, the requested device 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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Sprint PNS device is 
experimental for chronic pain syndrome. More research is needed to show 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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 15 units of procedure code 86003 billed for December 1, 
2021. 
 
You asked the Plan to pay for 15 units of procedure code 86003. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says they have agreed to pay for 30 units of 
86003; however, the additional 15 units billed exceed Medicare coverage limits. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 86003 will be covered only thirty (30) 
times in a year. Services exceeding this parameter will be considered not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional units of 86003 have not been met. Specifically, the Plan has already covered the 
maximum allowed 30 units for the year. Therefore, we decided that the Plan does not have to pay for 15 units 
of procedure code 86003 billed for December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot with ankle feature (L5968 and L5981). 
 
You asked the Plan to pre-approve an advanced foot with ankle feature. You say that the requested prosthetic 
leg with an advanced foot with ankle feature is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested prosthetic leg with an advanced foot with ankle 
feature. 
 
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 advanced foot with ankle feature. 
Our reviewer says that the enrollee does not meet criteria for the requested prosthetic leg with an advanced foot with ankle feature. Our physician reviewer found the requested prosthetic leg with an advanced foot and ankle 
feature exceeds the enrollees medical needs and is not medically necessary per Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) and per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k). The treating medical physician provider documentation does not support that the enrollee is a K3 
ambulator.  
 
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 advanced foot with ankle feature have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an advanced foot with ankle feature (L5968 and L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the provided medical records 
report morbid obesity, chronic hypercapnic respiratory failure, heart failure and obesity hypoventilation 
syndrome but do not document neuromuscular disease, thoracic restrictive disease or chronic respiratory failure 
secondary to chronic obstructive pulmonary disease. There is no support that the ventilator at issue meets 
Medicare criteria for medically necessary and reasonable for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 is stable for discharge and an IRF will 
provide the best opportunity to regain baseline quality of life. The Plan denied your request. The Plan says an 
intensive rehabilitation program 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 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. 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 76641 billed for date of service 
August 18, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee received multiple procedures on 
the date in question, and these services are supported as billed. The Plan denied your request. The Plan says the 
number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. It may be more appropriate to bill a single unit with a bilateral modifier rather than 
two separate units with the LT and RT modifiers. Based on this information, we decided that Medicare rules 
for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to 
pay for two units of procedure code 76641 billed for date of service August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have very severe COPD and 
malnutrition. ABGs during recent hospitalization are consistent with acute on chronic hypercarbic respiratory 
failure. You very likely have chronic CO2 retention and may benefit from BiPAP with AVAPS during sleep. 
Medicare does not cover a home ventilator when used as BiPAP. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested LTACH services are not medically 
necessary, reasonable, or appropriate for the diagnosis and condition of the member currently. 
 
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 can remain at the current ACH until such time no acute services are 
required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder 
(73222). 
 
You asked the Plan to pre-approve an MRI of the shoulder. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the shoulder. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has an ongoing neck 
problem. There is no documentation of conservative measures and physical therapy for shoulder pain. 
 
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 MRI of the shoulder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder (73222).
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 it is medically necessary to continue rehabilitation as 
an in-patient at a hospital. The Plan denied your request. The Plan says your needs can be met at a lower level 
of care such as skilled nursing facility (SNF), home health or home with outpatient setting. 
 
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 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. 
 
  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: 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 enrollees medical condition would benefit from 
inhouse rehab for strengthening and dialysis. The Plan denied your request. The Plan says the request is not 
medically necessary, the services they require custodial care and dialysis, can safely be received at a different 
setting, for example, home with home health. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold therapy water circulating cold pad with pump. 
 
You asked the Plan to pre-approve cold therapy pad with pump. You say that you will need this to use during 
your surgery recovery. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that fluid circulating cold pads are not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cold therapy pad with pump have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cold therapy water circulating cold pad with pump.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Injectafer. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Injectafer. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot walk and it is not safe for you to go 
home alone. The Plan denied your request. The Plan says the denial of SNF care is correct. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily 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 skilled nursing facility (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 skilled nursing facility (SNF) care.
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 acute inpatient rehabilitation to 
facilitate increased independence and return home with improved quality of life. The Plan denied your request. 
The Plan says criteria for admission to an IRF has not been met. 
 
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 does not require intensive or specialized rehabilitation. The enrollee does 
not require frequent physician oversight and has uncomplicated rehabilitation needs. 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.