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 enrollee is stable and suitable for 
transfer to an LTACH. You say that the enrollee cannot be adequately cared for in her current condition at a 
skilled nursing facility. You say that the enrollee requires prolonged hospitalization and close physician 
monitoring. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee's needs can safely be provided in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the out of network rates for a chest x-ray (code 71045) provided on July 
27, 2021, and a chest x-ray (code 71046) provided on July 28, 2021. 
 
You asked the Plan to waive the out of network rates for the chest x-rays. You say that the enrollee was on 
vacation and needed medical attention. You also say that this was a medical emergency, and out of network 
should not apply. The Plan denied your request. The Plan says the enrollee was stabilized and the out of 
network cost sharing applied. The Plan says that the enrollee has been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that the doctors who give 
you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care. 
 
The Plan says the enrollee must pay 30% coinsurance for the chest x-rays as part of an out of network hospital 
stay. Based on the plan contract, however, the enrollee cannot be asked to pay more than the in-network 
inpatient per day copayment, which includes the cost for the chest x-rays. Therefore, the chest x-rays are not 
subject to a separate out of network coinsurance. We decided that the Plan has to waive the out of network rates 
for a chest x-ray (code 71045) provided on July 27, 2021, and a chest x-ray (code 71046) provided on July 28, 
2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scleral contact lenses. 
 
You asked the Plan to pre-approve scleral contact lenses. You say that this is not a matter of convenience. You 
say that you have burning pain when your eyes are open. You say that the requested scleral contact lenses are 
supposed to help bathe the eyeball in fluid when the eye cannot do it itself. You say that you already have plugs 
in your tear ducts, but that this isn't working. You say that your doctors can provide the necessary clinical 
documentation to support the need for the requested lenses. The Plan denied your request. The Plan says the 
requested lenses are only covered for the diagnosis of aphakia, which the enrollee does not have. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered eyewear. The records provided do not show that 
you have a condition which allows for coverage of eyewear or contact lenses. Therefore, we decided that the 
Plan does not have to pre-approve scleral contact lenses.
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 enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower 
level of care may be considered when treatment has completed. 
 
 
 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 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 enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
 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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are having issues with your 
veins which are causing open wounds. You say that you are at risk of losing your legs if you don't sue the 
compression stockings being requested. The Plan denied your request. The Plan says the requested items are 
not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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's current medical condition does not require intensive physician or 
nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but 
the documentation does not reveal that this therapy must be only on an intensive level in an IRF or that the 
enrollee can tolerate an intensive rehabilitation program in an IRF. The therapy notes from March 7, 2022 state 
that the enrollee is limited by low endurance. The enrollee's needs can safely and effectively be met 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: 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 for the enrollee's 
condition. The Plan denied your request. The Plan says rules 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 is a 76-year-old woman with a history of heart disease, chronic 
obstructive pulmonary disease, diabetes, vascular disease, hypertension, and lung cancer, who was admitted to the hospital on March 3, 2022, with a right hip fracture, as well as a fracture of her left proximal humerus. In 
this case, 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 documentation does not 
support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of 
therapy services. While the enrollee will likely be able to fully participate in and benefit from therapy services, 
it is more appropriate that these services 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0242U) provided on August 30, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed as 
you believe these services were billed correctly. The Plan denied your request. The Plan says this claim has not 
been billed with an appropriate place of service. 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting 
which is not what the billed POS indicates. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (0242U) provided on August 30, 2021.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications. You received 
therapy with the most recent record from February 1, 2022 and were at a minimal to moderate assist level with 
transfers. Prior to that, in January 2022, you were at a minimal assist level for functional mobility. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that you started 
feeling numbness from the knees down and have not been able to walk normal. You say that you had to leave 
your job because you couldn't stand, and you need surgery as soon as possible. The Plan denied your request. 
The Plan says the 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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process distraction devices remain 
experimental and more research is needed. 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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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's current medical condition does not require intensive physician or 
nursing supervision in an IRF. The progress note from March 7, 2022 indicates that blood cultures were 
ordered due to low grade fever. The results of the blood cultures are not submitted, and it is not clear that the 
enrollee has completed his acute care medical management fever evaluation. The chest x-ray was negative, and 
the March 8, 2022 white blood cell count was reported as 6.7 but it is not clear that the enrollee's fever has 
resolved, and the work up was completed. Furthermore, this enrollee is at a high functional level already 
ambulating 100 feet with a RW and transferring with contact guard assist. He does not require 3 hours of daily 
therapy. Additionally, the therapy notes indicate he fatigues quickly therefore it is not clear that he can tolerate 
3 hours of daily therapy. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the cryoablation (47383). 
 
You asked the Plan to pre-approve the cryoablation (47383). You say that the member needs staging scans to 
continue with further treatment and needs the ablation procedure. The Plan denied your request. The Plan says 
that the request for cryoablation of a liver mass is 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 the cryoablation (47383). Our reviewer 
says that the renal cryoablation in this case is medically reasonable and necessary. Our physician reviewer 
found that staging studies have been completed and this lesion is appropriate for cryoablation. 
 
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 cryoablation (47383) have been met. Therefore, we decided that the Plan 
has to pre-approve the cryoablation (47383).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in a hospital and need to go to an acute 
inpatient rehab facility. The Plan denied your request. The Plan says care in a therapy unit (acute inpatient 
rehabilitation) 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 the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Therapy services may 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.