Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee should be admitted to the 
LTACH for ongoing acute care needs and close monitoring of their other complex medical conditions with an 
aggressive regimen of physical rehabilitation as tolerated. The Plan denied your request. The Plan says the 
LTACH services you are requesting do not meet the requirements for approval. 
 
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 more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility. Transfer to the 
LTACH would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended. 
 
 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: 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 you need long-term acute rehabilitation 
for severe wound care. The Plan denied your request. The Plan says the LTACH is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, nursing facility, 
outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that you were hospitalized for an infected right heel wound and 
cellulitis and underwent surgical debridement. Currently, you have wound vacuum-assisted closure and 
remains on intravenous (IV) antibiotics. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 
 
 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 pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you would highly benefit from custom foot 
orthotics. 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
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 after your surgery you need a facility that specializes 
in rehab for the heart. The Plan denied your request. The Plan says the request 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 that 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty. 
 
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 there is no detailed documentation of 
diagnostic imaging evidence of a large or irreparable rotator cuff tear or significant instability, deformity, or 
bone loss in the left shoulder. Additionally, there is no documentation of a recent trial and failure of reasonable 
and comprehensive less-invasive conservative care measures for the left shoulder. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested reverse total shoulder arthroplasty is not medically reasonable 
or 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 reverse total shoulder arthroplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93010) provided on December 12, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to 
support that the billed services were provided twice on the same date. Based on this information, we decided 
that the Medicare rules for the services have not been met. Therefore, we decided that the Plan does not have to 
pay for the services (93010) provided on December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) billed for date of service December 
22, 2021. 
 
You asked the Plan to pay for infrared therapy. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
 
  The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Based on this information, 
we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we decided that 
the Plan does not have to pay for infrared therapy (97026) billed for date of service December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device (E0676). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that your provider 
recommended you order the requested equipment, and you cannot afford to pay the amount out of pocket. You 
are requesting reconsideration and approval for the device. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare if you do not show you have a diagnosis of 
lymphedema or chronic venous insufficiency with venous stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression 
device (E0676).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Retacrit or Procrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the preferred drugs. The reviewer found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a static progressive forearm pronation/supination device. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a history of rheumatoid 
arthritis. A clinical progress note dated September 14, 2022 states she has a contracture of the left elbow. She 
continues to have reduced range of motion and function of the left elbow after left elbow capsular release and 
manipulation under anesthesia. She has been attending physical therapy but continues to have deficits with 
range of motion. The static progressive elbow stretching orthosis would be considered appropriate for the 
enrollee's medical condition and in accordance with accepted standards of medical practice. The medical 
literature considers it safe and effective for the enrollees condition of contracture and to maintain and enhance 
range of motion. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a static progressive forearm pronation/supination device.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73521 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 73521. You say that you are unable to see if the place of service 
is correct. The Plan denied your request. The Plan says it is inappropriate to bill an outpatient place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 73521 was billed with an outpatient place of service code. The records show that the 
enrollee was an inpatient at the time the services at issue were provided. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 73521 billed for date of service May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
August 5, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered bundled 
and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
August 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled therapy services. 
 
You asked the Plan to pre-approve additional home health skilled therapy services. You say that continued 
home health skilled therapy services are needed because you are not strong enough yet. You are still having 
dizziness and feel you needs more exercise and physical therapy. The Plan denied your request. The Plan says 
this is the third recertification for home health services. It appears that you are able to ambulate independently 
and would be able to continue exercises independently.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health skilled therapy 
services. Our reviewer says that additional home health skilled therapy services are not medically necessary. 
Our physician reviewer found the clinical documentation shows that you have met your documented physical 
therapy goals. The concern you raised is regarding dizziness, which is a medical issue as opposed to a physical 
therapy goal. Therefore, further home health skilled therapy is not medically appropriate based on available 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health skilled therapy services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve additional home health skilled therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on July 6, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you should not be 
assessed a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must a $195 
copayment per day for days 1 to 6; a $0 copayment for days 7 to 90.  
 
 
  You have been asked to pay $195 for inpatient mental health care. This item/service falls within the inpatient 
mental health care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental 
health care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve a transforaminal epidural steroid injection. You say that a transforaminal 
epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the requested 
transforaminal epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a transforaminal epidural steroid 
injection. Our reviewer says that a transforaminal epidural steroid injection is not medically necessary. Our 
physician reviewer found that the criterion of the LCD is 3 months or longer sustained improvement in pain 
relief and/or improvement in function of at least 50% measured from baseline using same before a repeat 
epidural steroid injection (ESI). This was not achieved and therefore, the request is deemed not medically 
reasonable or 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 a transforaminal epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection.