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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites).  The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility.  The requested treatments are not medically 
necessary at the LTACH level of care. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the IRF services 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 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. The 
enrollee was admitted for atrial fibrillation and a stroke and has been discharged home. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroscopy with meniscectomy (29880). 
 
You asked the Plan to pre-approve the left knee arthroscopy with meniscectomy. You say that the procedure is 
medically necessary. The Plan denied your request. The Plan says the requested surgery 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 the left knee arthroscopy with 
meniscectomy. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not show comprehensive less invasive 
conservative care measures. Considerable mechanical symptomatic issues are not evident. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the left knee arthroscopy with meniscectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a left knee arthroscopy with meniscectomy (29880).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories. 
 
You asked the Plan to pre-approve a power wheelchair with accessories. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 
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.  
 
The file shows that the enrollee does not have a mobility deficit that impairs your participation in MRADLs. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service January 1, 
2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99213 is bundled into payment for code 96372. 
 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 99213 
is a column II code to column I code 96372. 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 99213 billed for date of service January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789, G0481) provided on April 26, 2022. 
 You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. In addition, code 83789 is not separately payable when it is used to report specimen validity 
testing on specimens used for drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. Medicare rules also 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 lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. In addition, code 83789 is 
not separately payable. Therefore, we decided that the Plan does not have to pay for lab services (83789, 
G0481) provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(k0553). 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that you come from a family of diabetics and 
with your high iron it puts you at risk of diabetes and you feel this should be covered. The Plan denied your 
request. The Plan says the enrollee is not diabetic and is not on insulin and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(k0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that while the enrollee does not qualify for 
low dose computed tomography (LDCT) as they have less than 20 smoking pack years, they do have a personal 
history of cancer and their treatment would benefit from a CT of the chest. The Plan denied your request. The 
Plan says this service is not medically necessary. 
 
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 of the chest. Our reviewer 
says that the medical necessity of the requested service is not supported in the medical record. Our physician 
reviewer found the enrollee is asymptomatic related to the lungs and does not qualify for LDCT due to having a 
smoking history of less than 20 pack years. The notes mention a history of breast cancer, but no details are 
provided. There is no discussion or mention in the records about a suspicion of recurrence or metastasis. The 
last CT angiography of the chest was performed in 2019, and there is no recent plain chest x-ray. The criteria 
for coverage of a CT of the chest are not 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography (CT) of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a human floor lift. 
 
You asked the Plan to pre-approve a human floor lift. You say that it takes a long time to get off the floor if you 
fall. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a human floor lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pannulectomy and liposuction. 
 
You asked the Plan to pre-approve pannulectomy and liposuction. You say that you are hoping that these 
services will significantly lower your swelling and constant discomfort all the time. 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 pannulectomy and liposuction. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our reviewer found you have lymphedema and have a history of abdominal surgery.  The record 
provided does not indicate that the requested procedure is for the prompt repair of accidental injury or to 
improve the functioning of a malformed body member, or to diagnose or treat of an illness or injury. Therefore, 
you do 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 pannulectomy and liposuction have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pannulectomy and liposuction.
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 these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visits for assistance with activities of daily living 
and personal care (99509) provided from October 11, 2021, to January 4, 2022. 
 
You asked the Plan to pay for the home visits. You say that your Evidence of Coverage states that home health 
agency care and home health aide services are listed as covered benefits. The Plan denied your request. The 
Plan says the provider clearly lists on the reimbursement forms that the services that the rendered were 
emotional support services, managing medication, preparing meals, and housekeeping. The Plan also says that 
all services listed are custodial care services which are not covered by Medicare under any circumstance. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home visits have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. The Plan also confirmed with the provider that you have been told multiple 
times that you were not treated by home health care, but were treated by home care. Therefore, we decided that 
the Plan does not have to pay for the home visits for assistance with activities of daily living and personal care 
(99509) provided from October 11, 2021, to January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says LTACH is not 
medically necessary. The enrollees continued care needs include therapy to get them stronger, and a skilled 
nursing services for the tubes in chest and back. You can safely receive this care in another setting such as 
SNF. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where the enrollee 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 5 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 5 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found clinical 
documentation shows that wound care is stable/routine and there is no documentation of any medication 
changes or unstable conditions. Thus, 5 additional home health nursing visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health skilled nursing visits.
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 exceeds the criteria for a 
medically appropriate LTACH admission. You say that an LTACH is the appropriate level of care for this 
enrollee, and they are medically stable to be transferred to an LTACH at this time. 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you do not need a receiver but need help with a 
sensor. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 continuous glucose monitor (CGM).