Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacral augmentation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found percutaneous sacral augmentation is 
experimental for the treatment of osteoporotic insufficiency fractures of the sacrum. The services are therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous sacral augmentation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met. Our physician 
reviewer found that you are approved for a right total shoulder arthroplasty. You are medically stable with 
medical clearance for the procedure. The procedure is approved at the outpatient level and there is no 
documentation to support that you will require at least two midnights of inpatient hospital care for the approved 
procedure. The inpatient level of care is not reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
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 extended hospitalization that the 
enrollee requires would best be met by transferring the enrollee to the LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam treatment (PBT). 
 
You asked the Plan to pre-approve PBT. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found proton beam treatment (PBT) is not medically reasonable and necessary in this case. There is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for bladder cancer is superior, inferior, or equivalent to external beam radiation therapy or Intensity 
modulated radiation therapy (IMRT), with regards to 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 PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam treatment (PBT).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Insulin Pump Infusion Set Quick-set 23 9 MM Paradigm 
(A4230). 
 
You asked the Plan to pre-approve an Insulin Pump Infusion Set Quick-set 23 9 MM Paradigm. You say that 
the services are necessary. The Plan denied your request. The Plan says that based on the documentation 
provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that an infusion pump is covered for under certain 
circumstances. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Insulin Pump Infusion Set Quick-set 
23 9 MM Paradigm. Our reviewer says that the services are medically necessary. Our physician reviewer found 
you should be provided with the supplies as needed and should be on a continuous glucose monitor (CGM) so 
the hybrid closed loop system can be used correctly and to hopefully help avoid low blood glucose levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Insulin Pump Infusion Set Quick-set 23 9 MM Paradigm have been met. 
Therefore, we decided that the Plan has to pre-approve an Insulin Pump Infusion Set Quick-set 23 9 MM 
Paradigm (A4230).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization 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 left heart catheterization. Our reviewer 
says that the requested left heart catheterization is not medically necessary. Our physician reviewer found the 
enrollee had a negative radionuclide stress test. Documentation does not support the rationale for this invasive 
imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
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 is 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 documentation shows that you have complex functional impairments however no 
active medical comorbidities have been specified thus the complexity of your documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. Additionally, documentation does not show that you would be able to tolerate 
15 hours of therapy per week. 
 
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 expandable controller, electrical harness, electronic 
connection, seat elevator, attendant control, transit option, and footplate base modification. 
 
You asked the Plan to pre-approve expandable controller, electrical harness, electronic connection, seat 
elevator, attendant control, transit option, and footplate base modification. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules.  
The documentation shows that the enrollee has five out of five bilateral lower limb strength. The enrollee can 
perform self-feeding, grooming, and hygiene independently. This means the enrollees upper limb strength and 
function are adequate for the enrollee to be able to control the power options using their own switches which 
are included in the allowance of these power options. There is no medical need to control the three requested 
power options through the joystick. This means the upgraded electronics are not covered. The seat elevator and 
transit option do not serve a medical purpose and are not covered. An attendant control cannot be covered if a 
user-operated control is requested. Footplates and base modifications are miscoded and are considered 
unbundled. Based on this information, we decided that Medicare rules for coverage of expandable controller, 
electrical harness, electronic connection, seat elevator, attendant control, transit option, and footplate base 
modification have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable 
controller, electrical harness, electronic connection, seat elevator, attendant control, transit option, and footplate 
base modification.
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 services are medically necessary for your 
recovery. The Plan denied your request. The Plan says you may receive the care needed in a lower level 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. Our 
physician reviewer found your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that your 
functional status requires 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 inpatient rehabilitation facility (IRF) admission and services.
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 the requested continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF 
care. 
 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 
enrollee does not meet criteria for continued SNF care. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided 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 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: 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 enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the IRF services requested 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's functional status does not require intensive rehabilitation or frequent 
physiatry oversight. The enrollee's rehabilitation needs may reasonably be met in a variety of settings. 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 a Medtronic Infuse BMP-2 Allograft, Medtronic 
Mastergraft Allograft, and the Musculoskeletal Transplant Foundation (MTF) Trinity Allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the allografts 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the BMP-2 allograft is not approved by 
the Food and Drug Administration (FDA) for posterior spine use. The Trinity allograft is considered 
experimental in nature. The requested allografts are not considered medically necessary over the gold standard 
of iliac crest autografts. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Medtronic Infuse BMP-2 Allograft, Medtronic Mastergraft Allograft, and the 
Musculoskeletal Transplant Foundation (MTF) Trinity Allograft.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 improving with current treatment and should only require 
short-term additional acute care services that can safely be 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. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service July 7, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services are not supported for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 87653 and 87481 are column II codes to column I code 87801. 
These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met for codes 87653 and 87481. In addition, we have 
confirmed that code 87798 is a column II code to column I code 87801; however, 87798 was billed with a 
modifier.  
 
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 procedure code 87798. Our reviewer says that the use of the 
91 modifier is not supported in this case. Our reviewer found the laboratory report does not support that this 
testing was a separate repeat procedure from 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service July 7, 2022.