Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. The 
clinical note shows that the enrollee has met all PT goals and was discharged to a home program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found The enrollee received an effective therapy program which resolved his 
symptoms. He demonstrated capacity to continue it independently. No indication for continued unique input 
from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (A4239). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that you have been using the 
requested since January 1, 2022, with well-controlled sugars. You also say that you have not used your insulin 
in five days. The Plan denied your request. The Plan says you do not meet criteria for approval of the requested 
CGM. 
 
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 you do not use insulin with at least 
three daily injections, and you are not using a CSII pump. Based on this information, we decided that Medicare 
rules for coverage of a Freestyle Libre CGM sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor (CGM) sensor (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 28, 2022.

You asked the Plan to pay for subsequent nursing facility care. You say that the claim needs to be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 28, 2022.
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 feel the enrollee is qualified for IRF admission 
and services. The Plan denied your request. The Plan says the enrollee does 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in their current condition at a lower level and is ready to be transferred to an LTACH. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met at 
a lower level of care. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you disagree with the 
denial. The Plan denied your request. The Plan says additional trips would exceed 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 covers a maximum of 48 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
thirty-eight (38) one-way transportation trips out of the allowed forty-eight (48) one-way trips approved. Once 
48 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional non-emergent routine transportation trips (A0120).
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 did not provide an argument for coverage. The Plan denied 
your request. The Plan says you are currently in an inpatient rehabilitation facility, and you have not yet 
completed the full course of care in this setting. You continue to require intensive therapy.  As a result, transfer 
to a SNF is not appropriate because you are receiving adequate and appropriate care in the inpatient rehab 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have daily skilled nursing and therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. However, given the ongoing issues with 
encephalopathy and ascites, continued care in the acute inpatient rehabilitation facility is appropriate until you 
are stable to transfer to home or to a long-term care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 manual wheelchair and accessories coded as E1161, 
E2617, E1028, K0108 and E2624. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee's needs cannot be met using 
a facility chair. The enrollee has had falls from the facility chair, and these have not been as a result of repairs needed to the chair. The Plan denied your request. The Plan says the enrollee resides in a long-term care facility 
and the current chair meets the enrollee's needs and simply needs to be repaired. 
 
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 a wheelchair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee lives in a long-term care facility and uses an ultralight wheelchair. The 
enrollee falls when standing from the chair. The primary request for the manual tilt is so that the enrollee may 
sleep in the chair. A manual tilt chair is not medically necessary as it is not medically necessary per L33788. 
There is not a clinical consensus that the enrollee requires the custom cushion. It is recommended that the 
current chair is adjusted. Per Medicare Integrity Manual chapter 13 section 13.5.4 the requested cushion 
exceeds what is necessary to meet the enrollee's needs. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair and accessories coded as E1161, E2617, E1028, K0108 and E2624.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology testing (CPT 95941) 
provided on May 19, 2022. 
 
You asked the Plan to pay for intraoperative neurophysiology testing. You say that intraoperative 
neurophysiology testing was medically necessary. The Plan denied your request. The Plan says intraoperative 
neurophysiology testing does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 intraoperative neurophysiology testing. Our 
reviewer says that the requested intraoperative neurophysiology testing is not medically necessary in this case. 
Our physician reviewer found that the enrollee underwent sacroiliac joint fusion. This is not a type or surgery 
for which the Medicare LCD supports the use of intraoperative neurophysiology services. It did not specifically 
involve spinal instrumentation requiring pedicle screws or distraction, decompressive procedures on the spinal 
cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves 
is at risk, nor any other indication for which the Medicare LCD supports intraoperative neurophysiology 
services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative neurophysiology testing have not been met. Therefore, we 
decided that the Plan does not have to pay for intraoperative neurophysiology testing (CPT 95941) provided on 
May 19, 2022.
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. You say that the enrollee is stable and can benefit 
from an LTACH to regain their maximum level of functioning. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMems heart monitor device (33289). 
 
You asked the Plan to pre-approve a heart monitor device. You say that you disagree with the decision, since 
the information originally provided answered the denial rationale. The Plan denied your request. The Plan says 
there is not enough medical evidence that shows use of the device is helpful, safe and improves the quality of 
life. 
 
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 a heart monitor device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a heart monitor device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMems heart monitor device (33289).
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 respiratory failure, pneumonia, and peripheral vascular 
disease. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38747, 47379, 49010, and 49320 rendered 
on February 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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 38747: 
 
Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-
aortic and vena caval nodes (List separately in addition to code for primary procedure) 
 
CPT 47379: 
 Unlisted laparoscopic procedure, liver 
 
CPT 49010: 
 
Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) 
 
CPT 49320: 
 
Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by 
brushing or washing (separate procedure) 
 
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 in terms of CPT 38747, the 
procedure report does describe abdominal lymphadenectomy, regional, including celiac, gastric, portal, 
peripancreatic, with or without para-aortic and vena caval nodes. The procedure report documents "The 
decision was made to proceed with pancreaticoduodenectomy...Two firm lymph nodes were dissected away 
from the porta hepatis using scissors as well as electrocautery and delivered." There is a more appropriate code 
to report for service provided. In terms of CPT 47379, the operative report does not include documentation to 
verify unlisted laparoscopy liver procedure, and in this case, confirmation of an unlisted procedure cannot be 
confirmed as performed. In terms of CPT 49010, this code is not supported by the procedure report. When 
services are reported correctly, exploration would be inclusive to the primary procedure. Finally, in terms of 
CPT 49320, the procedure report does not describe Laparoscopy, abdomen, peritoneum, and omentum, 
diagnostic, with or without collection of specimens by brushing or washing (separate procedure). 
 
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 procedure codes 38747, 47379, 49010, and 49320 rendered on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240), and a retainer crown (D6750). 
 
You asked the Plan to pre-approve a pontic, and a retainer crown. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the medical criteria for D6240 or D6750 have not been 
met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic, and 
a retainer crown when the services are medically necessary and reasonable.  
 
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 pontic, and a retainer crown. Our 
physician reviewer found these dental services are not medically necessary due to the enrollee's poor 
periodontal condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic, and a retainer crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6240), and a retainer crown (D6750).