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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that not having SNF care would jeopardize the enrollee's 
ability to regain their maximum function. The Plan denied your request. The Plan says the Medicare guidelines 
for the SNF admission were not met and the enrollee can receive the services they need at home with home 
health. 
 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 that there is no documentation that the enrollee requires skilled nursing services, i.e., 
the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care or respiratory care. 
 
Based on the medical records provided this enrollee does require skilled therapy services, i.e., the specialized 
skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically 
necessary and reasonable treatment. The enrollee is walking greater than household distances with no assistive 
device with stand-by assistance and is supervision to modified independent for transfers and activities of daily 
living. Provided records do not document a significant decline in the enrollee's functional status to necessitate 
daily inpatient skilled therapy services. There is no documentation that the enrollee requires the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not support that services in the home with 
home health care or in a long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this item is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 documentation does not support that the enrollee needs complex medical 
treatment in a LTACH. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has a tracheostomy that needs care and 
management, which is requires frequent suctioning and continuous oxygen. You say the enrollee requires 
observation because they will try and pull the trachea tube out and will not have an airway if they do so. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary, and the enrollees needs 
can be met at a lower 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 has identifiable skilled nursing service needs but does not have identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis 
as an inpatient in a 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (head, foot, and height 
adjustments), without side rails, without mattress (E0297). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that your current bed is not a fully 
electric bed and does not incline high enough for you to be positioned correctly. You are having breathing 
issues along with aspiring throughout the day. The Plan denied your request. The Plan says the requested bed is 
not a covered benefit and does not primarily serve a medical purpose and which are not reasonable and 
necessary to treat an illness or injury are not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (head, foot, and height adjustments), without side rails, without mattress (E0297).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve spinal surgery with an out-of-network provider. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the requested provider and facility are out-
of-network and are not covered. 
 
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 
spinal surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve PT services. You say that you want the Plan to cover the services. The Plan 
denied your request. The Plan says the provider is not in-network. Theres no benefit for out-of-network 
coverage unless the services are urgent or cannot be provided in-network, or its an emergency. 
 
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 (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lateral sacral 
branches (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested procedure has been shown to lack efficacy with a very wide range of results 
published in the peer-reviewed literature. 
 
 
  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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation procedure of the lateral sacral branches (64625).
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 in pain and unable to move around on your 
own. The Plan denied your request. The Plan says the IRF services you are requesting 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (97598) provided on June 8, 2022. 
 
You asked the Plan to pay for debridement (97598). You say that the medical records required to reprocess the 
denied claim are attached. The Plan denied your request. The Plan says procedure code 97598 is an add-on 
code that was not billed with the appropriate primary procedure code. 
 
  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 97598 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for debridement (97598) provided on June 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided by a noneligible provider. 
 
You asked the Plan to pay for physical therapy. You say that this is the only physical therapy that has helped. 
The Plan denied your request. The Plan says this provider is not eligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires providers to be enrolled in the 
Medicare program, and an unlicensed provider is not eligible for Medicare participation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by a noneligible provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E1399). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is 
medically necessary. The Plan denied your request. The Plan says there is no documentation of insufficient 
upper extremity function. The note does say the enrollee continues to use a walker. Power mobility devices 
should be requested using specific HCPCS codes to reflect the specific device, as medical necessity criteria are 
device specific. Therefore, we cannot say a power wheelchair is reasonable or necessary at this time. The 
enrollee is not restricted from receiving the wheelchair, only that this will not be covered by their Medicare 
plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is inadequate documentation 
that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily 
living such as toileting, feeding, grooming, and bathing in customary locations within the home. The physical 
examination provided from an office visit on 08/30/2022 documents no gait examination to support the 
limitations as detailed above. Records show the enrollee is using a walker; no problems with use of the walker 
are documented. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. 
The Plan denied your request. The Plan says admission to an IRF is not medically necessary and the enrollee 
can receive the services they need at a lower level of care like at a skilled nursing facility (SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. At the current functional mobility, the enrollee 
does not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach in an IRF. The 
enrollee's rehabilitation needs can be safely met in a lower intensity setting. 
 
The Documentation does not support the medical necessity for admission to an IRF due to lack of medical 
complexity, and nursing needs. While the enrollee would benefit from physical therapy and occupational 
therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such 
as in a SNF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle group 1 heavy duty, patient 
weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says the request for a power operated vehicle does not meet 
medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 power operated vehicle. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is documentation that you 
have a personal mobility deficit that impairs participation in mobility related activities of daily living such as 
toileting, feeding, grooming, and bathing in customary locations within the home. Your mobility deficit cannot 
be helped using a walker or manual wheelchair. Provided medical records document that you are safely able to 
use a walker and manual wheelchair in your home. You were approved for a standard manual wheelchair on 
08/16/2022. Records also indicate you use a walker for mobility. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle group 1 heavy duty, patient weight capacity 301 to 
450 pounds (K0801).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA), chest 
(71275) provided on February 20, 2022. 
 
You asked the Plan to pay for the CTA. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed 
tomographic angiography (CTA), chest (71275) provided on February 20, 2022.