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 you are requesting reconsideration for 
the denial of an LTACH admission. You say the LTACH is the appropriate level of care for this enrollee, and 
they are medically stable to be transferred to the LTACH level of care at this time. The Plan denied your 
request. The Plan says the enrollee does not meet the medical necessity and established criteria for the 
requested LTACH admission. 
 
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 provided at the current facility until more 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 the LTACH would not be clinically advantageous 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cardiology services. You say that you need this service, and you have 
already had an appointment with this provider. You did not know they were out-of-network. The Plan denied 
your request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 
cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
rendered October 6, 2022. 
 
You asked the Plan to pay for the services. You say that you would like this downcoded emergency department 
visit reconsidered. The Plan denied your request. The Plan says the emergency department (ED) notes do not 
document that the severity of the presenting problem was of immediate significant threat to life or 
physiological function, or that a high level of medical decision making was required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99284. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99284) rendered October 6, 2022.
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 IRF care 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 on review of the available records; the enrollee does not meet Medicare coverage criteria for IRF admission. The enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are 
identified or documented. The enrollee independent in mobility and does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The documentation does not support necessity for admission to an IRF and the complexity of the 
enrollee's nursing, rehabilitation and medical needs does not require an acute hospital inpatient rehabilitation 
stay with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from occupational 
therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in-
home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pulmonary rehabilitation services. You say that this is medically necessary 
for this patient and should be covered. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 
pulmonary rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit injections. 
 
You asked the Plan to pre-approve Procrit injections. You say that the records provided support the need for the 
requested Procrit injections. The Plan denied your request. The Plan says the criteria for medical necessity have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit injections. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there is no recent hemoglobin, 
which is required just prior to starting an ESA. Last was on January 25, 20223, more than 6 weeks ago. The 
requested injections are not medically necessary. Given the enrollee's platelets are at 70 and low, a dose 
reduction may want to be considered. In addition, recent labs were not submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Procrit injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planning.. You say that this is a medical 
necessity. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
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 medical records were submitted for review. The Plan 
denied your request. The Plan says that the admission to an IRF is 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 enrollee does not have complex nursing or rehabilitation needs. 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 the 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 acute IRF admission and 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 you disagree with the denial for admission to a SNF. 
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 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 the enrollee does not require daily skilled nursing or skilled therapy services. The 
enrollee does not meet the 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression 
(PILD) services. 
 
You asked the Plan to pre-approve the PILD services. You say that the medical records provided support the 
need for the services in dispute. You say that the requested treatment is clinical proven, safe, and effective to 
decompress the spinal canal by removing small portion of lamina and hypertrophic ligamentum flavum, leaving 
the structural stability of the spine intact. You say that because the enrollee is a Medicare beneficiary, she is 
inherently part of the Medicare Clinical trial. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that PILD for LSS is not reasonable and necessary and may 
only be covered under the context of a clinical trial.   
We looked at the file and Medicare rules. There is no documented evidence that the beneficiary is enrolled in a 
clinical trial. Based on this information, we decided that Medicare rules for coverage of the PILD services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Image-Guided 
Lumbar Decompression (PILD) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has severe obesity, obstructive sleep apnea, and obesity hypoventilation syndrome. There is no 
diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. The enrollee has had a home 
ventilator since 2021. The records include what appears to be a device download covering December 7, 2022, 
to February 5, 2023, that shows no device use. The ventilator is currently being used in average volume-assured pressure support (AVAPS) mode, which can be provided with bilevel positive airway pressure 
(BiPAP). There is no evidence that BiPAP with AVAPS has been tried and failed as an outpatient. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP, or in the treatment of 
obesity hypoventilation syndrome. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says this 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. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the exam on 
February 24, 2023, showed minor findings in the sphenoid sinus, but no acute pathology in the brain. The 
reason for a repeat exam has not been detailed, and the medical necessity of a repeat CT scan has not been 
established in the records submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the brain.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet denervation services. 
 
You asked the Plan to pre-approve facet denervation services. You say that the records provided support the 
need for injection services in dispute. The Plan denied your request. The Plan says , based on the clinical 
information they received, the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves is only covered when 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 facet denervation services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation about the degree and duration of pain relief from the prior radiofrequency ablation.  The 
procedure is not medically reasonable and 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 facet denervation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet denervation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the records provided support the need 
for the requested services. The Plan denied your request. The Plan says the enrollee has not had high risk 
findings on a stress test and is not going to have high risk surgery. The Plan says that there are other tests that 
the enrollee can have to evaluate their heart arteries that are safer. 
 
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 left heart catheterization. Our reviewer 
says that left heart catheterization services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found a radionuclide stress test was negative for ischemia. The medical records 
provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
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 services are medically necessary. The Plan 
denied your request. The Plan says your needs can be met in an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.