Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that your blood test results 
indicate that you are borderline diabetic. You say that you were referred to this doctor. You say that you need 
to find out what is causing your inflammation. you also say that this is the only doctor that does this testing. 
The Plan denied your request. The Plan says medical nutrition therapy is for people with diabetes, renal 
(kidney) disease (but not on dialysis), or after a kidney transplant when referred by your doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk without assistance. The Plan 
denied your request. The Plan says this is not medically 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 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 based on the medical records provided, there is no documentation that further daily 
skilled services are required. You are using a wheeled walker with contact guard assistance to walk household 
distances and are modified-independent for transfers. The provided records do not document a significant 
decline in your functional status to necessitate further daily inpatient skilled therapy 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen 
(74160). 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the submitted records do not 
document any details of the enrollee's abdominal pain. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the abdomen (74160).
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated 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 the enrollee does not need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. While the enrollee may benefit 
from physical or occupational therapy, her needs can be safely provided in a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this to start living a normal life again. The 
Plan denied your request. The Plan says you can be treated 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 the records show that you do ot require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement, but 
you can receive further services 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 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 this is medically necessary. The Plan denied your 
request. The Plan says no skilled nursing needs or skilled therapy needs are identified that require the requested 
level of 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to ADLs with minimal supervision.  Daily skilled services are not 
shown to be 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not agree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says you do 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. As of 9/15/2022, you were ambulating 30 feet with a rear 
walker with modified independence. You are independent with bed mobility and modified independent with 
transfers. You require stand by assistance to supervision for activities of daily living. You have had some 
decline in function in comparison to your baseline level of function, but you do not require the intensity of 
therapy services provided on acute inpatient rehabilitation. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 26, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve circumferential lipoplasty. 
 
You asked the Plan to pre-approve circumferential lipoplasty. You say that this surgery is needed because the 
enrollee has pain in the abdominal region. The Plan denied your request. The Plan says this 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 circumferential lipoplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 40-year-old woman who underwent gastric bypass in 2009 
which resulted in massive weight loss, with redundant skin and soft tissue which is nearly circumferential. It is 
noted that the enrollee has pain when she pushes, pulls, and squats. The documentation does not sufficiently 
support that circumferential lipoplasty is medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of circumferential lipoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve circumferential lipoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous laser ablation therapy. 
 
You asked the Plan to pre-approve endovenous laser ablation therapy. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the patient does not meet criteria for endovenous laser 
ablation therapy. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that endovenous laser ablation therapy is only coverable 
if the patient has reflux of the venous meeting certain criteria.  
 
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 endovenous laser ablation therapy. Our 
reviewer says that endovenous laser ablation therapy is not medically necessary. Our physician reviewer found 
the medical records do not indicate that there is significant reflux as there are no measurements of 500 
milliseconds or greater in the saphenous or perforator veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous laser ablation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve endovenous laser ablation therapy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance used with a therapeutic CGM device 
provided on November 20, 2021. 
 
You asked the Plan to pay for a supply allowance used with a therapeutic CGM device. The Plan denied your 
request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services 
related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service 
Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. 
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to 
the terminal illness until the first day of the month following the month in which hospice was revoked or 
discharged.  
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 a supply allowance used with a therapeutic CGM device 
provided on November 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management injections to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve OON pain management injections. You say that this is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers that can provide the requested 
services. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON pain management injections. Our reviewer says that it is not 
medically necessary for the enrollee to receive the requested services out-of-network. Our physician reviewer 
found the requested injections are a simple straightforward procedure that can be performed in network. There 
are no special circumstances described in the submitted records.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON pain management injections have not been met.  
 
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 OON pain management injections. Therefore, we 
decided that the Plan does not have to pre-approve pain management injections 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 an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) and monthly supplies for use of device coded K1018 (K1019x5). 
 
You asked the Plan to pre-approve a tremor stimulator device and supplies. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary. This product 
is still being studied to see if the treatment is reasonable and necessary. Additional research is needed to 
determine if this device provides a benefit of equal or greater value than the current recognized methods of 
treating essential tremor. 
 
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 tremor stimulator device and supplies. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence to support that the requested wrist-worn 
neuromodulation therapy device is medically reasonable and necessary for the enrollee in this case. There is 
lack of evidence to support this device over traditional treatment of essential tremor. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tremor stimulator device and supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of 
the wrist (K1018) and monthly supplies for use of device coded K1018 (K1019x5).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 17004) provided to the 
enrollee on October 4, 2021. 
 
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 code was not appropriate for 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 code 17004 is "Destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more 
lesions." 
 
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 records. Our reviewer found that the records do not support the use of CPT 
17004. The documentation shows that 14 lesions were treated. The more appropriate code would be CPT 
17003.  
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 surgical services (procedure code 17004) provided to the enrollee on October 4, 2021.
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 would benefit most from IRF care. The 
Plan denied your request. The Plan says criteria 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 the enrollee was admitted to the hospital after a fall on September 5, 2022. She was 
given intravenous antibiotics for cellulitis and was found to have a deep vein clot in her left leg. She was treated with Eliquis.  
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not 
require intensive physician and nursing oversight in an IRF. While the patient may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that the 
patient requires this 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.