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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis 
(74176) and lower extremity (73700). 
 
You asked the Plan to pre-approve the CT scans. You say that the CT scans are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the CT scans. Our reviewer says that 
this service is not medically necessary. Our physician reviewer found the physical examination reported shows 
the abdomen to have no distention or erythema. The notes clearly say that bowel sounds are normal in all 4 
quadrants and there is no tenderness to palpation in all 4 quadrants and no organomegaly. There are no 
laboratory studies other than the urinalysis and there is no evidence of plain films of the hip done first. 
 
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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the abdomen and pelvis (74176) and lower extremity 
(73700).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say a 
total electric hospital bed (E0265) is not covered; the height adjustment feature is a convenience feature. Total 
electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have 
to pre-approve the total electric hospital bed (CPT code E0265).
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 LTACH services will improve the 
enrollee's respiratory condition and avoid unnecessary hospital readmissions. The Plan denied your request. 
The Plan says the criteria for LTACH services have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. 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: 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 does not require short-terms 
acute care but is not fit to go home. You say the enrollee requires the LTACH. The Plan denied your request. 
The Plan says the criteria for LTACH services have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. 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: 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 a delay in care will have a detrimental effect on the 
enrollee's safety and their ability to recover to the fullest extent. The Plan denied your request. The Plan says 
the criteria for IRF services 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical management of a bowel obstruction. Medical problems are stable, and there are no 
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 this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for superficial radiation therapy 
(CPT code(s): G6001 X 25 and 77401). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says it is not considered standard of care and there is not enough medical evidence to show 
that this type of radiation treatment is effective to treat the enrollee's skin cancer. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found billing for daily simulations or image-guided radiation therapy (IGRT) would not be furnished 
in accordance with accepted standards of medical practice. 
 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guidance for superficial radiation therapy (CPT code(s): G6001 X 25 and 
77401).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be in a rehab facility so that 
they can get the proper help to get their strength back. The Plan denied your request. The Plan says that this is 
not medically necessary. The enrollee must complete their full course of acute hospital treatment. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found acute inpatient rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 enrollee does not meet criteria for SNF admission. 
 
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 based on the medical records provided there is no documentation that the enrollee 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex 
wound care or respiratory care. Based on the medical records provided this enrollee does require skilled 
therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to 
safely and effectively provide medically necessary and reasonable treatment. Based on the medical records 
provided there is no documentation that daily skilled services are required. The enrollee "is walking well, doing 
laps around the nursing station and even not having to use the walker." He is supervision for transfers and is 
supervision to minimum assist for activities of daily living. Provided records do not document a significant 
decline in the enrollees functional status to necessitate daily inpatient skilled therapy services. Based on the 
medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, 
only 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal, tooth #19 
(CPT code D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says this request exceeds your benefit frequency limit. 
 
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. Review of the file shows that 
pontic - porcelain fused to high noble metal for tooth #19 was done previously on July 11, 2019. The Plan 
contract says D6240: one (1) procedure per tooth every five (5) plan years. Therefore, you exhausted your 
benefit. Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble 
metal, tooth #19 (CPT code D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a speech generating device (E2510) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a speech generating device to be provided by an OON provider. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that the 
requested speech generating device can be approved through an in-network provider. 
 
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 
a speech generating device (E2510) to be provided by an out-of-network (OON) provider.
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 enrollee does not meet criteria for IRF admission. 
 
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 complexity of the enrollee's 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 surgical repair of a hip fracture after a fall. 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, in 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the PalinGen Xplus skin substitute graft. 
 
You asked the Plan to pre-approve the PalinGen Xplus graft. You say that the patient would benefit from the 
use of these dressings to reduce healing time due to high risk of infection. The Plan denied your request. The 
Plan says this is still considered experimental for the patient's condition. 
 
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 PalinGen Xplus graft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record shows that this patient is suffering with multiple ulcerations to their 
bilateral lower extremities. The patient is noted to be diabetic. The patient is currently undergoing sharp 
debridement, offloading of feet, and dressings including silver alginate. PalinGen X Plus is an amnion product 
utilized for many different applications, including diabetic wounds. 
 
Currently amnion wound coverings are not standard of care. Standard of care continues to consist of sharp 
debridement of the ulceration on a routine basis, dressings including alginates and skin protectorates, and offloading of the ulcerative areas. It is also imperative that a diabetic patient keep their blood glucose under 
good control. In this particular case, in the six-week interval between the enclosed medical progress notes, the 
patients ulcerations have reduced in size slightly from an area perspective. It appears that amnion applications 
would exceed the patients current medical needs at this point. Studies also advise that further investigation of 
amnion wound coverings are needed in order to confirm their efficacy. As such, the use of these dressings in 
this case is not considered 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 the PalinGen Xplus graft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the PalinGen Xplus skin substitute graft.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the medical records submitted do not establish that the IRF admission is 
reasonable and 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.