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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in a less intensive setting 
of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You had a total knee replacement in December of 
2021 and are living at home with stiffness, pain and difficulty ambulating despite home health physical therapy 
services. Your 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 you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for an office visit provided on November 9, 2021. We decided that the Plan 
does not have to pay for the Fundus Photography provided on November 9, 2021.  
 
We decided that the Plan has to pay for the office visit provided on November 9, 2021.  
 
You asked the Plan to pay for the office visit. The Plan says that the office visit is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny the office visit. Specifically, the Plan has not provided the rule that supports their denial of 
coverage for an office visit. Therefore, we decided that the Plan has to pay for the office visit provided on 
November 9, 2021.  
 
We also decided that the Plan does not have to pay for Fundus Photography provided on  
November 9, 2021. 
 
You asked the Plan to pay for the Fundus Photography. The Plan says that the Fundus Photography is excluded 
from coverage. 
 
The Plan follows Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening. 
 
We looked at the file and the Medicare rules. Medicare says that Fundus Photography is not covered for routine 
screening. Therefore, we decided that the Plan does not have to pay for Fundus Photography provided on 
November 9, 2021. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion placement surgery (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion placement surgery. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 Vertiflex Superion placement 
surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this device is experimental and more research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex Superion placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion placement surgery (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tubing extension and infection control supplies (S1015 
and S8301) provided on October 12, 2021. 
 
You asked the Plan to pay for the tubing extension and infection control supplies. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 
and S8301 have a Status Indicator of I. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This 
means that CPT code S1015 and S8301 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of the tubing extension and infection control supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for the tubing extension and infection control 
supplies (S1015 and S8301) provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Powered Upper Extremity Range of Motion Assist 
Device (MYOPRO) (L8702). 
 
You asked the Plan to pre-approve the Myopro device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is experimental. 
 
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 Myopro device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental and more research is needed to show its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Myopro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Powered Upper Extremity Range of Motion Assist Device (MYOPRO) (L8702).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 29, 2021, to 
October 5, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says that these services were not 
medically necessary at an inpatient hospital level. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department (ED) on September 29, 2021, after a 
ground level fall resulted in a left hip fracture. He was evaluated and treated with analgesics and admitted. He 
tested positive for COVID-19 on admission. He had been vaccinated. He underwent surgery. He was stable 
post-operatively and was discharged on October 5, 2021. The review indicates that the record showed that at 
the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 29, 2021, to October 5, 2021.  
 
 
 
 
 
 
 
 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: 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 IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug rehabilitation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve drug rehabilitation services. You say that the care with the OON provider is 
not up to standards. The Plan denied your request. The Plan says there are in-network providers available to 
provide the care you need. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
drug rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on 
February 3, 2021, through July 14, 2021. 
 
You asked the Plan to pay for the mechanical traction therapy. You say that you would like reconsideration 
because you qualify for coverage. The Plan denied your request. The Plan says coverage is limited to manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy (97012) provided on February 3, 2021, 
through July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that this is covered by Medicare and is necessary for 
you. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for this device as 
you do not require insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily administrations. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Freestyle Libre sensors (K0533). 
 
You asked the Plan to pay for the Freestyle Libre sensors. You say that you are currently using insulin and have 
had worrisome and dangerously low glucose levels. You purchased a CGM for $350 but cannot continue to 
purchase through the provider as that would put a big strain on your finances. The Plan denied your request. 
The Plan says the enrollee does not meet the coverage criteria for the Freestyle Libre sensors. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre sensors have not been met. 
Therefore, we decided that the Plan does not have to pay for the Freestyle Libre sensors (K0533).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you currently have a need for medical 
care at all times. The Plan denied your request. The Plan says rules for coverage for home health services have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on December 
8, 2021. 
 
You asked the Plan to pay for dental services. You say that you did not realize that opting out harmed your 
patients as a result. The Plan denied your request. The Plan says payment cannot be made to an opt-out 
provider. 
 
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 dental 
services provided by an opt out-provider on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies rendered on December 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the diabetic testing supplies rendered on December 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were 
not urgent, emergent, or approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on January 20, 2022, by an out-of-
network (OON) provider.
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 LTACH is the most appropriate level of 
care for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH care 
is correct. 
 
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 continues to receive acute care services that have not been denied. There 
are no services that the enrollee requires at the LTACH that are not available at the current 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home health services provided on September 9, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home health services. You say that it was medically necessary to treat the 
enrollee and an authorization could not be completed in a timely manner. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no approved authorization, and it 
was determined that the services rendered were not urgent or emergent. Also, the services rendered could have 
been provided by an in-network provider. 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Home health services provided on September 9, 
2021 by an out-of-network (OON) provider.