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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that you will not be released from the hospital until 
you are approved to go into a SNF. You state you cannot walk or move by yourself, and unable to cut up your 
food or hold a beverage. The Plan denied your request. The Plan says authorization denied because SNF care is 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. 
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 
level of care (ex. home, AL, LTC). 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested device. You say that the device will allow close monitoring of 
the enrollee's pulmonary pressures and volume status. The Plan denied your request. The Plan says this device 
should only be approved for clinical trials. 
 
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 requested device. Our physician 
reviewer found that the CardioMEMS device is placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure. The clinical study on 
which approval was based showed improved clinical outcomes and decreased hospitalizations in those whom 
the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and 
was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided at a 
network facility. 
 
 
 You asked the Plan to pre-approve the SNF care. You say that after 10 days of rehabilitation you had trouble 
managing your pain medication and did not get a chance to start rehabilitation. You say you need to build 
strength in your legs to help you start walking. The Plan denied your request. The Plan says because SNF care 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are 
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a 
daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any 
parental medication, complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbation of chronic medical problems. Your physical function is at or near your new 
baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 
services 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided at a network facility.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records do not show that the enrollee has a need for a complex 
rehabilitation team and dedicated rehabilitation doctor. 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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. At the current functional level, the enrollee's does not need 3 hours a day, five 
days a week of IRF therapies with interdisciplinary management and his needs can be met in an alternate and 
lower setting such as in an outpatient setting. IRF admission is not medically necessary based on medical 
stability, lack of medical complexity, and lack of rehab nursing needs and high functional level. Documentation 
does not support the necessity for admission to an IRF. While the enrollee may benefit from physical therapy 
and occupational therapy the enrollee's rehabilitation can be safely provided at a lower intensity and alternate 
setting such as in an outpatient 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 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee is not medically complex and does not require 
oversight by a doctor three times a week. The Plan says that the enrollee does not require a multidisciplinary 
approach for intensive therapy three hours per day. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. At the current functional level with slow progress, the enrollee will not make a 
significant functional progress in the predicted 7-10 days in IRF. The enrollee's does not need 3 hours a day, 
five days a week of IRF therapies with interdisciplinary management and her needs can be met in an alternate 
and lower setting such as in a skilled nursing facility (SNF.) An IRF admission is not medically necessary 
based on medical stability, lack of medical complexity, and lack of rehabilitation nursing needs. 
Documentation does not support the necessity for admission to an IRF. While the enrollee may benefit from 
physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided at a lower 
intensity and alternate setting such as continuation in in an SNF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) and destruction procedures 
on benign or premalignant lesions of the integumentary system (17004) provided August 10, 2021. 
 
You asked the Plan to pay for the outpatient visit. You say that just because this provider does not accept 
Medicare should not be a condition that the Plan should not have to pay on the claims. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) and destruction procedures on benign or premalignant lesions of the 
integumentary system (17004) provided August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripherala nerve stimulation (PNS). 
 
You asked the Plan to pre-approve peripherala nerve stimulation. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 peripherala nerve stimulation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is an experimental device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripherala nerve stimulation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripherala nerve stimulation (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided 
September 6, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that based on CPT and/or CMS guidelines, a 
provider who prepares a separately identifiable interpretation which contributes to the diagnosis and treatment 
of a patient is entitled to payment. The Plan denied your request. The Plan says services paid to another 
provider. 
 
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 71045 is radiologic examination, chest.  
We find that CPT code 71045 is not supported in the medical record. Specifically, multiple attempts were made 
to obtain additional information from the provider without success. Without the information, the Plan cannot 
determine how the enrollee came to the servicing provider or where the services are medically necessary. 
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 radiologic examination, chest (71045) 
provided September 6, 2021.
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 enrollee requires a multi-disciplinary 
approach to help manage her multiple medically complex issues. The Plan denied your request. The Plan says 
the LTACH would add no additional services. 
 
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 physician 
reviewer found that in this case, the enrollee was admitted to the acute care hospital with congestive heart 
failure exacerbation. She required a mitral valve replacement. The record indicates that she has had a 
complicated post operative course and still requires ongoing acute care services. She continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH 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 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 IRF is medically necessary, and the enrollee's 
needs cannot be safely met by home health or skilled nursing. The Plan denied your request. The Plan says 
authorization denied because IRF is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as skilled nursing facility (SNF). 
 
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 medical problems are stable, and 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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee can develop blood clots without this 
medication. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 pre-approve Eliquis for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combination, bilateral, lumbo-sacral, hip, femur orthosis 
(L1690) provided on January 11, 2022. 
 
You asked the Plan to pay for the combination, bilateral, lumbo-sacral, hip, femur orthosis. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this 
service has not been reported correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code L1690 is not supported in the record. Specifically, this claim was billed with separate 
diagnosis codes for the left and right side. There is a more appropriate bilateral diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of the combination, bilateral, lumbo-sacral, hip, 
femur orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the 
combination, bilateral, lumbo-sacral, hip, femur orthosis (L1690) provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64635, 64636). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet join injections are covered when the criteria 
listed in the Medicare Rules section are met. 
 
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 facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the utilization limit is two 
sessions of RFA within one spinal region in a 12 month period; this request exceeds that limit. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64635, 64636).
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 IRF is medically necessary. The Plan denied your 
request. The Plan says authorization denied because IRF care is not medically necessary, and your needs can be 
met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF. Specifically, you do not require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 pay for the critical care services (99291) provided on July 8, 2021. 
 You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this service exceeds the MUE. 
 
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services (99291) provided on July 8, 2021.