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

 
We decided that the Plan does not have to pre-approve reduction mammoplasty. 
 
You asked the Plan to pre-approve reduction mammoplasty. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 reduction mammoplasty. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our reviewer found the enrollee has large droopy breasts, present after massive weight loss. The enrollee 
suffers from chronic neck pain, for which she has been seeing a chiropractor. The documentation in the 
Surgical Consult - Breast Reduction does not include any notation regarding intertriginous maceration, 
infection, shoulder grooving, or upper extremity paresthesia. It is not documented that the enrollee's neck pain 
appears to be directly correlated to macromastia. The case file does not document clearly demonstrated 
interference with normal activities of daily living, as noted by a breast specific questionnaire for activities of 
daily living. It is not documented that the enrollee's symptoms persist despite appropriately fitted supporting 
garments. Therefore, the enrollee does not meet criteria for the requested 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 reduction mammoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve reduction mammoplasty.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says on review, they have determined that continued SNF 
coverage beyond the last covered date of May 18, 2022, is not medically reasonable or necessary. 
 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 continued SNF services. Our reviewer 
says that this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 continued SNF services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring. 
 
You asked the Plan to pre-approve ambulatory blood pressure monitoring. The Plan denied your request. The 
Plan says this 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 ambulatory blood pressure monitoring. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the submitted clinical documentation does not support that the enrollee 
met either Medicare criteria for ambulatory blood pressure monitoring for suspected white coat hypertension, 
as there were not 2 elevated blood pressure readings done at each office visit, and no normal blood pressures 
recorded outside of the office visit.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulatory blood pressure monitoring have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra injections. 
 You asked the Plan to pre-approve Inflectra injections. The Plan denied your request. The Plan says the 
enrollee has not met the step therapy requirements. 
 
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 Inflectra injections. Our reviewer says 
that Inflectra is not medically reasonable and necessary in this case. Our physician reviewer found that there is 
no indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects 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 Inflectra injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Inflectra injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine, 
without contrast material (72148). 
 
You asked the Plan to pre-approve an MRI. You say that this MRI is medically necessary as the enrollee's back 
pain is getting worse. The Plan denied your request. The Plan says the requested MRI is not medically 
necessary, as the medical records provided show that the enrollee is making progress with physical therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
criteria for coverage of an MRI are not met in this case. Our physician reviewer found the enrollee began 
physical therapy on April 13, 2022. At the last visit on June 2, 2022, the pain had improved from a 6/10 to a 
4/10 and was described as confined to the right hip which incidentally shows degenerative osteoarthrosis on x-
ray. In addition, there is a partial MRI report of the lumbar spine dated June 2, 2022. There is no impression. 
The combination of facts in this case does not provide medical necessity for an MRI of the lumbar spine and 
certainly not a repeat exam. The records do not show any red flags such as absent reflexes, and the requested 
MRI is not recommended 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lumbar spine, without contrast material (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve special supplemental benefit for the chronically ill. You say that this is 
medically necessary. The Plan denied your request. The Plan says you do not qualify for these benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition and a high-risk for hospitalization. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of special supplemental benefit for the chronically ill have not been met. Specifically, the 
documentation submitted by your provider indicates that you are not at risk for hospitalization. Therefore, we 
decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says based on Medicare guidelines, the skilled nursing facility services you 
are requesting does 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 services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) neurologist. 
 
You asked the Plan to pre-approve an office visit. You say that this out-of-network provider is the only doctor 
that specializes in vestibular neuritis that you have been able to locate. The Plan denied your request. The Plan 
says these services have been requested by an out-of-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 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 
an office visit to be provided by an out-of-network (OON) neurologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like approval for these services. 
The Plan denied your request. The Plan says these services can be provided in-network. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244) and a tub stool or bench 
(E0245). 
 
You asked the Plan to pre-approve a raised toilet seat and a tub stool. You say that the requested items are 
medically necessary because the enrollee is home following hip replacement surgery. The Plan denied your 
request. The Plan says the requested items are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats and a tub stool or 
bench are not covered because they are not primarily medical in nature.  
 
While a raised toilet seat and a tub stool or bench 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 
raised toilet seat (E0244) and a tub stool or bench (E0245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you had a knee replacement surgery 
and need to go to physical therapy as well as to other appointments. The Plan denied your request. The Plan 
says once you use all of your 48 one-way trips, your benefit limit has been met. The Plan also says that there is 
not an exception that would allow the Plan to cover unlimited rides as requested. 
 
  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 up to 48 one-way trips per year to other health care related locations (such 
as to the pharmacy or specialist appointments).  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from June 1, 2021, through 
June 7, 2021, at DRG 640. 
 
You asked the Plan to pay for the inpatient services at DRG 640. You say that you recommend resequencing 
diagnosis code N17.9 to a secondary coding position which would change the DRG to 640. You say that the 
chart was coded correctly, and your findings should be reviewed. The Plan denied your request. The Plan says 
the secondary diagnosis code supports DRG 641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code N17.9, defined as acute renal 
failure, unspecified. 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 inpatient services at 
DRG 640. Our reviewer says that DRG 641 is appropriate. Our physician reviewer found that diagnosis code 
G93.41 metabolic encephalopathy should be deleted due to a discrepancy in documentation. Diagnosis code 
N17.9 acute kidney injury unspecified is supported and is sequenced as a secondary diagnosis. The review has 
determined that DRG 640 is not appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from June 1, 2021, through June 7, 2021, at DRG 640.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that there is not a provider with this equipment 
within a one-hour drive or that is willing to deliver. The Plan denied your request. The Plan says the services 
have been requested by an out-of-network provider. The plan has recommended 3 in-network providers, all of 
which are less than a one-hour drive from you. 
 
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 
a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at 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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this patient is in need of daily 
cardiologist visits to follow the patient until stabilized. You also say that you will need a cardiology consult, 
nephrology consult, physical and occupational therapy, nutritional support, and wound care. The Plan denied 
your request. The Plan says you are receiving appropriate in-patient acute care and does not require transfer to 
a Long-Term Acute Care Hospital (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 there is no documentation provided indicating medical necessity for LTACH 
services. Our physician reviewer also found that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis provided to the enrollee 
on February 4, 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 documentation submitted did not sufficiently support the billed supply code, and there is 
evidence of misrepresented services. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the medical documentation does not support the medical necessity for the dispensed 
upper extremity orthosis.  
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 pay for a shoulder elbow wrist hand orthosis provided to the enrollee on February 4, 2022.