Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 that there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires 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 the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services rendered on October 4, 
2021, through October 8, 2021. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the enrollee did not meet 
Medicare criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our 
reviewer says that this enrollee did not require inpatient mental health treatment beyond the dates in question as 
he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. Our physician reviewer found it 
did not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the patients condition or for the purpose of diagnosis. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient mental health services rendered on October 4, 2021, through 
October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous neurostimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this is 
not a late or last treatment for pain. 
 
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 services. Our physician 
reviewer found that the enrollee is being treated for post-laminectomy syndrome. He presented with pain in the 
cervical thoracic, and lumbar spine that radiates to the upper and lower extremities as well as around to the ribs. 
The exam reveals pain with lumbar extension and bilateral lateral flexion. Gait is antalgic with a forward-
leaning posture. He is noted to have had memory problems for years.  However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There is indication that he may have undergone 
physical therapy; however, the dates are not clear and not noted to have been recent. Current conservative 
treatments include walking and medications. The use of spinal cord stimulation is indicated as a late/last-resort 
treatment for failed back surgery. Such a 'late/last-resort' is not evident in this case. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested spinal cord stimulator (percutaneous implantation of the neurostimulator 
electrode array, epidural), in this case, is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous neurostimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care from the out-of-network (OON) 
provider for services January 1, 2022 forward, including on dates of service January 21, 2022 and January 27, 
2022. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. Additionally, the services provided in this case were rendered by an out of network 
provider, without prior authorization.  
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this case will not be provided in an emergency or urgent care situation. The Plan is not 
providing these services and is not making arrangements to provide these services. Additionally, the Plan will 
not issue payment for services rendered by an out of network provider, without prior authorization. Therefore, 
we decided that the Plan does not have to pre-approve chiropractic care from the out-of-network (OON) 
provider for services January 1, 2022 forward, including on dates of service January 21, 2022 and January 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide. 
 
You asked the Plan to pre-approve Budesonide. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare 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 Budesonide.  
 
 
 Benefits for Budesonide 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: 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 you require IRF care. The Plan denied your request. 
The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 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 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 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 the enrollee remains critically ill and requires ongoing acute care services. The 
enrollee 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 enrollee meets criteria for an IRF admission. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet 
the requirements for approval. 
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continued skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a continued SNF admission. You say that you live in an assisted living 
facility, and they might not take you back due to your condition, but you are not sure yet if they will take you 
back. You also say that you cannot do anything on your own yet. The Plan denied your request. The Plan says 
that your request for approval of continued admission in skilled nursing facility does not meet the requirements 
for approval. 
 
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 a continued SNF admission. Our 
reviewer says that you qualify for ongoing SNF coverage. Our physician reviewer found you do not have 
documented skilled nursing needs. You do have documented skilled therapy needs. Our reviewer found that 
you are functioning below your baseline. You have made progress with therapy. The documentation does not 
yet establish that you have reached a plateau in progress. Our physician reviewer also found that ongoing daily 
skilled services are required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. 
 
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 continued SNF admission have been met. The Plan must continue coverage 
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has 
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-
approve a continued skilled nursing facility (SNF) admission.  
 
 
 
 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 pre-approve the percutaneous implantation of neurostimulator 
electrode array, epidural (63650) and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural 
(63650) and implantable neurostimulator electrode. You say that the service is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary because the records show that this 
request is not a late or last treatment for pain. The member has not tried physical therapy or chiropractic 
treatment in over 20 years and not tried acupuncture in over 40 years. The member refuses to see a 
neurosurgeon or try an epidural steroid injection, and the pain provider indicates that the member could try 
MILD for your spinal stenosis. 
 
The Plan follows Medicare rules. Medicare rules say that SCS therapy should be considered as a late option 
after more conservative attempts, such as medications, physical therapy, psychological therapy or other 
modalities have been tried. 
 
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 percutaneous implantation of 
neurostimulator electrode array, epidural (63650) and implantable neurostimulator electrode. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the member does not meet the criteria 
for this service. 
 
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 percutaneous implantation of neurostimulator electrode array, epidural 
(63650) and implantable neurostimulator electrode have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (63650) and 
implantable neurostimulator electrode (L8680).
Appeal type: SNF
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. You say that the enrollee is not safe to send home. The Plan 
denied your request. The Plan says the enrollee is receiving adequate care in the inpatient rehabilitation facility. 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to the hospital for treatment of cardiac arrest with shock. He stabilized 
medically and was discharged to an inpatient rehab facility for intensive therapy. The most recent therapy 
documentation indicates he is able to ambulate up to 150 feet with a walker and contact guard assistance. He is 
able to accomplish bed mobility and transfers without hands on assistance. He has tolerated inpatient rehab 
services and continues to improve with daily skilled nursing and/or skilled therapy services. There is no 
indication that transfer to a skilled nursing facility is required. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the programming device evaluation/adjustments and 
fluoroscopy time provided during pacemaker placement on November 16, 2021, billed with codes 93280 and 
76000. 
 
You asked the Plan to pay for the billed services. You say that this was denied as inclusive, but these were 
separately provided and must be paid. The Plan denied your request. The Plan says there is a PTP edit which is 
not appropriate to bypass in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that codes 76000 and 93280 are column II codes in relation to column I code 
33208. Code 93280 was not billed with an appropriate modifier to bypass this edit. Code 76000 is billed with 
modifier -59, but the operative report only documents that five minutes of fluoroscopy were provided during 
the procedure. There is no evidence that this imaging was unrelated to the procedure which is required to 
support modifier -59. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the programming device evaluation/adjustments and fluoroscopy 
time provided during pacemaker placement on November 16, 2021, billed with codes 93280 and 76000.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient admission for 5 days. 
 
You asked the Plan to pre-approve an inpatient admission for 5 days. You say that treatment with intravenous 
Dihydroergotamine (IV DHE) is medically appropriate and necessary. The Plan denied your request. The Plan 
says that there is no sufficient data supporting an inpatient stay. 
 
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 an inpatient admission for 5 days. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found you would like to treat the enrollee with intravenous Dihydroergotamine (IV DHE) to 
break their migraine cycle. Our reviewer found that per a note on the request, inpatient admission is required, 
the dosing of the medication needs to be given every 8 hours for 11 doses, and contracted infusion centers 
cannot assist as the enrollee needs cardiac and neurological monitoring. Our physician reviewer also found that 
the record shows that the admitting physician reasonably expects that the enrollee's necessary hospital care will 
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 an inpatient admission for 5 days have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient admission for 5 days.  
 
 
 
 
 
 
 
 
 
 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.