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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to regain maximum 
function. 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. 
There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain functional status. The enrollee can receive further services at a lower 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 inpatient rehabilitation admission is a medically 
necessary. The Plan denied your request. The Plan says the requested service is not a medical necessity. 
 
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 most recent therapy notes indicate that the enrollee is able to ambulate up to 40 
feet using a walker and contact guard assistance.  
 The enrollee requires minimal assistance to contact guard assistance for bed mobility and transfers. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
improvement however, the documentation doesn't support that the enrollee would meet criteria for admission to 
an acute rehabilitation facility. There are no complex nursing or rehabilitation needs. While the enrollee has 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213), chiropractic manipulative treatment 
(98942, 98943) and manual therapy (97140) provided on November 8, 2021. 
 
You asked the Plan to pay for chiropractic care. You say that no one from the Plan contacted you to tell you 
that you had reached your allotted benefit for your treatment. You say that you are unclear how you would 
have exceeded your benefits and do not agree with the denial of payment for your November 8, 2021, visit. The 
Plan denied your request. The Plan says the maximum benefit has been paid for this service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan also says that you are limited to 18 
combined visits per calendar year. 
 
 
 
 
 The EOC confirms that you are limited to 18 chiropractic care visits per year. The records show that received 
18 total visits from January 28, 2021, through November 1, 2021. Specifically, you have exceeded your 
maximum benefit for chiropractic care with the Plan. Therefore, we decided that the Plan does not have to pay 
for an office visit (99213), chiropractic manipulative treatment (98942, 98943) and manual therapy (97140) 
provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 83789 is bundled into 
payment for code 80307. 
 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 code 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services coded 81455 provided on 
September 24, 2021. 
 
You asked the Plan to pay for the genetic testing services coded 81455. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was denied 
correctly based on Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with CPT 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing services coded 81455 have not been met. Therefore, we decided that 
the Plan does not have to pay for the genetic testing services coded 81455 provided on September 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you have been recently diagnosed with a 
severe neurological disorder of having a vein getting lose from your brain, it is causing a lot of back pain and 
dizziness. Your primary care physician referred you to a neurologist. You are unable to avail to public 
transportation due to your vertigo, imbalance, and other medical issues. The Plan denied your request. The Plan 
says you are requesting an additional seven (7) miles for a total of 57 miles and your benefit only allows 50 
miles. You have exceeded your benefit limit. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan says routine transportation is limited to ground transportation only to destinations within 50 
miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
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 meets MCG criteria for 
LTACH level of care and is included in clinical documentation for authorization request. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to 
a long-term acute care hospital. 
 
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 appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of an advanced skin substitute. 
 
You asked the Plan to pre-approve the application of an advanced skin substitute. You say that the enrollee is 
extremely high risk of having an infection progress up his leg, resulting in a below knee or possible above knee 
amputation. You say that the application of an advanced skin substitute would aid in the healing of the wound 
faster, would likely prevent the need for further surgery, and prevent the possible loss of part or all of the limb. 
The Plan denied your request. The Plan says the records do not show that the enrollee has had greater than 4-
weeks of conventional therapy, whether the enrollee has adequate perfusion of the leg, or whether the enrollee 
has had optimal glycemic management for diabetes. 
 
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 application of an advanced skin 
substitute. Our reviewer says that the application of an advanced skin substitute is not considered medically 
reasonable and necessary in this case. Our physician reviewer found it is well established that the enrollee is 
suffering with an ulceration to the posterior plantar aspect of their heel. The enrollee is noted to be diabetic 
with diminished pedal pulses. On September 19, 2022, the ulceration measured 4.2 cm x 3.0 cm x 0.1 cm.  The following visit, dated September 26, 2022, demonstrates an improved ulceration measuring 3.7 cm x 3.0 cm x 
0.1 cm.  The enrollee is receiving standard wound care at this point. The progress notes demonstrate that the 
enrollee has had improvement in their ulceration in only one week with standard wound care. It appears that 
application of advanced skin substitute at this point would exceed Medicares medical necessity guidelines. 
 
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 application of an advanced skin substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the application of an advanced skin substitute.
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 appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they 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 the enrollee was admitted to acute hospital on September 18, 2022, for a 
pericardial effusion. Medical history includes hypothyroid, chronic obstructive pulmonary disease, aortic 
stenosis, diastolic heart failure, atrial fibrillation. Per the September 26, 2022 progress note, the enrollee came 
to the hospital with a syncopal episode in therapy. The enrollee's current level of function on September 27, 
2022, is ambulation distance 200 feet using a front wheeled walker, contact guard assist sit to stand, stand to 
sit, and gait training. There are no complex nursing or rehabilitation needs. While the enrollee has 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 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 this enrollee has had multiple 
readmissions to the hospital due to inadequate post-acute care and LTACH would greatly help with this issue. 
The Plan denied your request. The Plan says the request is not medically necessary because the records do not 
show that it is safe for the enrollee to leave the hospital at this time because the enrollee has hepatic 
dysfunction and the enrollee's medical conditions/treatment are not stable. 
 
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 appears to still be somewhat unstable requires short-term additional 
acute care services that can be safely administered at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on November 
10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support 
payment for code 83789-59 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (83789-59) provided on November 10, 2021.
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 need the best medical care with intensive 
rehabilitation so you can get better and go home. 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 the documentation does not reveal that you require this therapy on an intensive IRF 
level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) with a 
prosthetic valve. 
 
You asked the Plan to pre-approve TAVR with a prosthetic valve. You say that the records provided support 
the need for TAVR. The Plan denied your request. The Plan says there is no documentation showing that the 
enrollee symptoms come from the aortic valve. The Plan says that the requested surgery is very risk and may 
not help the enrollee. The Plan says that the enrollee does not have a valve area less than 1 centimeter squared. 
 
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 TAVR with a prosthetic valve. Our 
reviewer says that TAVR with a prosthetic valve is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the most recent echocardiogram showed aortic stenosis, with valve area 
over 1 sq cm and moderate aortic regurgitation. Guidelines would not support aortic valve replacement based 
on the submitted medical records.  As a result, at this time the requested TAVR would not be considered 
medically necessary in this patient's clinical management based on the submitted documentation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR with a prosthetic valve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) with a prosthetic valve.
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 inpatient rehabilitation facility admission is a 
medical necessity. The Plan denied your request. The Plan says the services requested are 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 the enrollee has a medical history including diabetes mellitus, morbid obesity 
and memory loss who was admitted to the hospital after a mechanical fall resulted in a right hip fracture. The 
enrollee was treated surgically. Postoperatively the enrollee required treatment for a urinary tract infection and 
has stabilized medically. There are no complex nursing or rehabilitation needs. While the enrollee has 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 IRF admission and services.