Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 10 
additional PT visits. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have received four months of therapy for low back pain. An 
effective therapy program is in place, and you have improved and have little pain. You are able to do a home 
exercise program and continued input from a skilled therapist is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on August 22, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided to the 
patient for use during surgery to prevent deep vein thrombosis. The Plan denied your request. The Plan says 
this device is not covered for this purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for prevention of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive electrophysiologic evaluation. 
 
You asked the Plan to pre-approve comprehensive electrophysiologic evaluation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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.  
 
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 comprehensive electrophysiologic 
evaluation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee was cardioverted in 2021 and treated with medication, without arrhythmia recurrence thereafter. As 
such, there is insufficient documentation to support the medical necessity for electrophysiologic study and 
catheter ablation in this enrollees 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 comprehensive electrophysiologic evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve comprehensive electrophysiologic evaluation.
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 your legs are weak due to a side effect from 
medicine and you can barely walk. You say that you have been advised to use a walker but even with a walker 
you still have difficulty. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for leg weakness and muscle inflammation. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: 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 you feel your condition is worsening because you are 
not receiving the level of care and therapy that is needed at the skilled nursing facility. You say you want to go 
to an actual inpatient rehab so you can regain your strength and maximum functions. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that you would meet criteria for admission to an acute inpatient 
rehabilitation facility. You can receive further services 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 IRF admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency (RFA) ablation. 
 
You asked the Plan to pre-approve thermal facet joint RFA ablation. 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 an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 thermal facet joint RFA ablation. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
show you have had two diagnostic medial branch blocks performed. The review has determined that you do not 
meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal facet joint RFA ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve thermal facet joint radiofrequency (RFA) ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair. 
 
You asked the Plan to pre-approve wheelchair. You say that the enrollee resides in the facility and received 
skilled care. The Plan denied your request. The Plan says Medicare does not separately cover DME in a skilled 
nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a wheelchair.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 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 have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
enrollee's care needs 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this ventilator is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found this patient may 
benefit from BiPAP with average volume-assured pressure support and a backup rate during sleep as an 
outpatient. This has not been tried and shown to fail as an outpatient. The patient does not have a diagnosis for 
which Medicare covers a home ventilator, and Medicare does not cover a home ventilator when used at settings 
that can be provided by BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 8, 2022 to 
March 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the determination to remove diagnosis code A41.9, sepsis unspecified organism and secondary diagnosis code R65.20 severe sepsis without septic shock 
remains upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported diagnosis codes A41.9 (sepsis, unspecified organism) and R65.20 (severe sepsis without 
septic shock). In this case, the documentation does not consistently and completely support the assigned 
principal or secondary diagnoses codes with the DRG. The replacement of the DRG is upheld as it is supported 
by the medical documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 8, 2022 to March 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal allograft procedure (20930). 
 
You asked the Plan to pre-approve the spinal allograft procedure. You say that this service is 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 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 spinal allograft procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that 
shows this requested allograft to be an effective and/or safe treatment for the noted pathology. 
 
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 spinal allograft procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal allograft procedure (20930).
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 are not strong, you are blind in one eye and if 
you fall, there is no one to help you. You say your doctor agrees that you need additional care and would 
benefit from this. The Plan denied your request. The Plan says criteria for admission to a SNF have 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs can 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) infusion 
supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223) provided 
August 30, 2022, to September 3, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that you provided IV infusion therapy for the 
enrollee at home. The home infusion therapies allow the enrollee to continue medical treatment at a lower cost 
than if they were to remain in the hospital. The Plan denied your request. The Plan says these items are not 
covered by Medicare or the Plan.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the disposable drug delivery system (A4305) infusion supplies not used with external infusion pump, per 
cassette or bag (list drugs separately) (A4223) provided August 30, 2022, to September 3, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's needs around the clock care and 
cannot get the care they need at home as they would be unsupervised for 8 hours a day. The Plan denied your 
request. The Plan says that 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 care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have documented skilled nursing needs in the form of a new 
feeding tube. The enrollee does not have documented skilled therapy needs and appears unable to participate in 
skilled therapy. Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
   
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. 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 IMRT is clinically indicated (i.e., medical necessity 
criteria will be met) when highly conformal dose planning is required. 
 
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 IMRT. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found IMRT is not medically necessary in this 
case. The records do not show why IMRT is required over other standard external beam radiation therapy 
methods. There is no documented rationale of the advantage of IMRT versus other radiation therapy methods, 
that dose escalation is planned, or that the target volume is in close proximity to critical structures that must be 
protected as required by the coverage rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT).