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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 enrollee was admitted for cholangitis and respiratory failure. Medical problems 
are stable. 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. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for weakness, leg pain, and a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial as you 
have no blood flow in your legs. The Plan denied your request. The Plan says Medicare does not cover elastic 
stockings even though you need them for leg swelling or varicose veins. Medicare covers durable medical 
equipment that can be rented and reused. Stockings are nonreusable and are not rented. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 20, 
2021, to May 22, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the level of care in this case. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation does not indicate that the enrollee was expected to 
require hospital services that would likely to cross 2 midnights as she was stable on admission and only 
required coordination for outpatient workup for the mass and continuation of rate control for her atrial 
fibrillation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 20, 2021, to May 22, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0429, A0425) provided on April 9, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically reasonable and 
necessary. The Plan denied your request. The Plan says that the ambulance transport was not medically 
necessary in this case. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says that the enrollee's presenting symptoms meet prudent 
layperson criteria for emergency care. Our physician reviewer found the enrollee was being treated for renal 
failure at the transferring hospital and was transported by ground ambulance to a second hospital for 
nephrology care which was not available at the transferring facility. The documentation supports that the 
ambulance transport on April 9, 2022, was medically reasonable and necessary 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 ambulance services have been met. Therefore, we decided that the Plan has to 
pay for ambulance services (A0429, A0425) provided on April 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
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 the home ventilator. Our physician 
reviewer found there is no diagnosis of COPD, neuromuscular disease, or thoracic restrictive disease, so the 
enrollee does not have a diagnosis for which Medicare covers a home ventilator. The appropriate treatment of 
this enrollee's obesity hypoventilation syndrome (OHS) is bilevel positive airway pressure (BiPAP) during 
sleep, and this has not been tried as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRE (CPT code 0601T) and an inpatient admission. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of IRE in the setting of locally advanced pancreatic 
adenocarcinoma have not been demonstrated in the peer-reviewed literature. The Plan states more research is 
needed to show safety and efficacy of the procedure. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested treatment is not a standard treatment in the medical community at this time. The 
requested procedure is therefore 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 services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve IRE (CPT code 0601T) and an 
inpatient admission.
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 take care of yourself and need skilled 
nursing. The Plan denied your request. The Plan says the requested SNF services do 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 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 that you do not qualify for SNF coverage. You do not have documented skilled 
nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of your 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 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: 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 attached is the requested information for 
denial. You have attached the enrollee's BIPAP settings in the hospital that were not effective. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with or without 
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 record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a step therapy exception cannot be granted. 
 
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 the drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has iron deficiency anemia. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this requested power wheelchair with multiple power options cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the enrollee 
is not at high risk for skin breakdown. The enrollee is incontinent but has chronic impaired mobility and no 
skin issues. The enrollee does not use a ventilator or intermittent catheterization. The requested wheelchair and 
accessories are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; cholecystectomy with 
cholangiography provided to the enrollee on May 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says when a laparoscopic procedure is converted to an open procedure, only the open procedure 
should be reported. 
 
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 47563 is "Laparoscopy, surgical; cholecystectomy with 
cholangiography." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record includes one 
procedure report, describing a laparoscopic converted to open cholecystectomy. No additional medical records 
were provided. If a laparoscopic procedure is converted to an open procedure, only the open procedure may be reported. Neither a surgical laparoscopy nor a diagnostic laparoscopy code shall be reported with the open 
procedure code when a laparoscopic procedure is converted to an open procedure. Of note, diagnosis Z53.31 
Laparoscopic surgical procedure converted to open procedure was reported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laparoscopy, surgical; cholecystectomy with cholangiography provided to the enrollee on May 
3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel coded as 81206, 81162, 81275, 
81276, 81292, 81295, 81298, 81301, 81317, 81404, 81194 provided February 24, 2022. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that this letter and attached documents support 
the medical necessity of the tests requested to assist in the treatment prognosis and diagnosis for this type of 
cancer. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 pay for the Tempus Gene Panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that a Tempus gene panel was medically 
reasonable and necessary for the enrollee in this case. 
 
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 Tempus Gene Panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel coded as 81206, 81162, 81275, 81276, 81292, 81295, 81298, 
81301, 81317, 81404, 81194 provided February 24, 2022.