Persius/hicric huggingface dataset:
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 
enrollee does not meet criteria for IRF admission. 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 unilateral knee arthroplasty. 
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 enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit purchased on January 17, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you would like this claim reprocessed 
based on information you heard about COVID-19 home test kits being covered. The Plan denied your request. 
The Plan says these tests were purchased prior to the start date of Medicare coverage of home health COVID-
19 test kits. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will not provide payment for over-the-
counter COVID-19 tests obtained prior to April 4, 2022 
 
We looked at the file and Medicare rules. In this case, the COVID-19 home test kit was purchased prior to 
April 4, 2022. Based on this information, we decided that Medicare rules for coverage of the COVID-19 home 
test kit have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home 
test kit purchased on January 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that the requested continuation of SNF 
care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 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 continued SNF services. Our reviewer 
says that the enrollee does not meet criteria for continued SNF care. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, 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 continued SNF services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were not performed in the inpatient setting. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, there is no specific 
clinical rationale for the requested 3-level bilateral lumbar medial branch blocks at the L3-4, L4-5, and L5-S1 
levels. The review has determined that you do not meet the coverage criteria detailed in the LCD. 
 
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 joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) 
services after June 17, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF services. You say that you do not have the 
equipment to go home yet. The Plan denied your request. The Plan says your needs are custodial at this time. 
Custodial care is not a covered benefit. 
 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 the SNF services. Our reviewer says 
that you no longer meet the criteria for coverage for SNF services as of June 17, 2022. Our physician reviewer 
found, at the time of admission, you required skilled rehab services to improve function due to weakness and 
deconditioning. You received skilled care and improved; however, your functional improvement and medical 
conditions had stabilized by June 17, 2022, and you did not require any further inpatient skilled rehab services. 
Your function was at or near your prior level of function and you could be discharged to a lower level of care 
for further services. As of June 17, 2022, you required custodial services and did not require any skilled 
services on an inpatient basis at a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the continuation of skilled nursing facility (SNF) services after June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips to travel 
to and from fitness clubs. 
 
You asked the Plan to pre-approve additional non-emergency transportation trips to travel to and from fitness 
clubs. You say that your social security income is only $320, which is not enough for you to pay for the Uber 
service. You also say that only 24 one-way trips per year is not enough. The Plan denied your request. The Plan 
says this service is a covered benefit, but you have exceeded the limits set in the subscriber agreement. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional non-emergency transportation trips to travel to and from fitness clubs have not been met. 
Specifically, there is a benefit for 24 one-way trips per year, and more than 24 trips are not covered. Therefore, 
we decided that the Plan does not have to pre-approve additional non-emergency transportation trips to travel 
to and from fitness clubs.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have been in a room, in a chair under 
quarantine since you were in the hospital, and you never received therapy. You say that you are able to feed 
yourself and bathe a little and you need and you are ready for skilled nursing facility care. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary. 
 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 services. Our reviewer says that 
SNF care is not medically necessary. Our physician reviewer found that from a nursing perspective, you 
received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical 
therapy and occupational therapy. You were at minimal to moderate assist level for functional mobility 
including gait to 60 feet x 2. You required varying assist with activities of daily living. There are no identifiable 
skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled 
nursing or therapy services on a daily basis. As a practical matter, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (K0553) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says they confirmed with the 
enrollee that the denied item was never ordered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, the dates on the proof of delivery that was submitted do not match up with the date of service. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (K0553) provided on November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of an oral bisphosphonate and zoledronic acid before they will approve the requested drug. The provided 
records do not show that the enrollee has tried and failed both required drugs. The records also do not show that 
both required drugs would be less effective or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on October 14, 2021, to October 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says medical records submitted do not support the Health Insurance Prospective Payment System 
(HIPPS) code used in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the available documentation in 
the case file does not support an active diagnosis of aphasia. The documentation also does not support the 
diagnosis of malnutrition or risk of malnutrition as an active diagnosis. 
 
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 skilled nursing facility (SNF) services provided to the enrollee on October 14, 2021, to October 
31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF services. 
 
You asked the Plan to pre-approve continuation of SNF services. You say that you need to become stronger. 
You say that your memory is still foggy and you live alone at home. The Plan denied your request. The Plan 
says based on Medicare guidelines, your request for approval of continued admission in skilled nursing 
facility does not meet the requirements for approval. 
 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 continuation of SNF services. Our 
reviewer says that continuation of SNF services is not medically necessary. Our physician reviewer found that 
from a nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation 
services, you received physical therapy and occupational therapy. You were at an independent to contact guard 
assist level for functional mobility including gait to 250 feet. You required varying assist with activities of 
daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy 
service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from June 
27, 2022, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care from June 27, 2022, and 
forward. You say that the continuation of inpatient psychiatric care from June 27, 2022, and forward is 
medically necessary. The Plan denied your request. The Plan says the continuation of inpatient psychiatric care 
from June 27, 2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient psychiatric 
care from June 27, 2022, and forward. Our reviewer says that the continuation of inpatient psychiatric care 
from June 27, 2022, and forward is not medically necessary. Our physician reviewer found this enrollee did not 
appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis beyond the date in question. I am unable to 
find an individualized treatment plan however the entire record is not present. It did appear that the records 
were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does 
not meet the criteria for continued inpatient psychiatric care from June 27, 2022, and forward as this enrollee 
was cooperative/compliant with treatment while not showing any threats to safety. 
 
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 continuation of inpatient psychiatric care from June 27, 2022, and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of 
inpatient psychiatric care from June 27, 2022, and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve operative placement, revision, replacement, or removal 
of the spinal neurostimulator system components to provide spinal electrical stimulation (63650). 
 
You asked the Plan to pre-approve operative placement, revision, replacement, or removal of the spinal 
neurostimulator system components to provide spinal electrical stimulation. You say that operative placement, 
revision, replacement, or removal of the spinal neurostimulator system components to provide spinal electrical 
stimulation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve operative placement, revision, 
replacement, or removal of the spinal neurostimulator system components to provide spinal electrical 
stimulation. Our reviewer says that operative placement, revision, replacement, or removal of the spinal 
neurostimulator system components to provide spinal electrical stimulation is not medically necessary. Our 
physician reviewer found that the enrollee does not have an evidence-based indication for a spinal cord 
stimulator and has not had a surgical consultation for her extruded disc. The request is not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of operative placement, revision, replacement, or removal of the spinal 
neurostimulator system components to provide spinal electrical stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve operative placement, revision, replacement, or removal of 
the spinal neurostimulator system components to provide spinal electrical stimulation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit purchased on January 29, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you would like this claim reprocessed 
as you needed to purchase a COVID-19 test. The Plan denied your request. The Plan says payment will not be 
made for this test kit based on Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will not provide payment for over-the-
counter COVID-19 tests obtained prior to April 4, 2022. Based on this information and a date of service being 
before April 4, 2022, we decided that Medicare rules for coverage of the COVID-19 home test kit have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit purchased 
on January 29, 2022.