Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
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 this service.  Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that the 
enrollee was admitted to the acute inpatient psychiatric hospital on February 16, 2023 with Major Depressive 
Disorder, Recurrent, Severe without Psychotic Features. Based upon the review of the records provided, it was 
not expected that this enrollee would improve in a reasonable period of time for the dates in question as she did 
not have suicidal or homicidal ideation, auditory, or visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee does 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 does not appear that active treatment was taking 
place beyond the date in question. It does not appear that the requested services are reasonably expected to 
improve the enrollees condition or that the services are for the purpose of a diagnosis beyond the date in 
question. It does appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, the enrollee does not meet the criteria for coverage of acute inpatient psychiatric 
hospital care as of March 16, 2023 forward.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued acute inpatient psychiatric hospital care.
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 LTACH services are necessary because 
you are getting worse. The Plan denied your request. The Plan says LTACH services are not medically 
necessary. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative electroencephalogram (EEG) testing  provided 
on January 11, 2021. 
 
You asked the Plan to pay for the EEG testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the intraoperative EEG testing is experimental.  
 
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 pay for the EEG testing. Our reviewer says that the 
requested EEG testing is not considered medically reasonable and necessary. Our physician reviewer found the 
records provided for review did not readily support that a classic EEG was performed. Nor was there any formal diagnostic utility present in this case of having an EEG recorded during the course of the procedure. 
Rather, performance of EEG during this type of surgery would have exceeded the enrollees clinical needs. It 
would not have been expected to have been beneficial for the diagnosis or management of the enrollees 
condition, in as much it was 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 EEG testing have not been met. Therefore, we decided that the Plan does 
not have to pay for intraoperative EEG testing (CPT 95955) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the SSBCI program 
denial. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of the SSBCI benefits have been met. Therefore, we decided that the Plan does 
not have to pre-approve the SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous intraoperative neurophysiology 
monitoring (IONM) (G0453), and short-latency somatosensory evoked potential (SEPs) (95938) provided on 
December 8, 2022. 
 
 You asked the Plan to pre-approve the IONM and short-latency SEP. You say that the services should be 
covered. The Plan denied your request. The Plan says the services in this case are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it is not anticipated that such monitoring will be 
medically necessary for the typical cervical or lumbar root decompression procedures. 
 
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 IONM and short-latency SEP. Our 
reviewer says that the IONM and short-latency SEP are not medically necessary. Our physician reviewer found 
the provided documentation indicates that the enrollee's surgery took place below the terminus of the spinal 
cord. There was no formal risk of additional nerve or spinal cord injury. The reviewer found that the enrollee 
underwent a standard single level procedure for which the guidelines state that it is not anticipated that such 
monitoring will be medically necessary for the typical cervical or lumbar root decompression procedures. 
Therefore, the reviewer found that the IONM and short-latency SEP was 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 the IONM and short-latency SEP have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the continuous intraoperative neurophysiology monitoring (IONM) 
(G0453), and short-latency somatosensory evoked potential (SEPs) (95938) provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 30, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee is currently in a rehab 
facility. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on October 7, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the labs were ordered by the referring physician. The 
Plan denied your request. The Plan says a panel cannot be unbundled. 
 
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 urinary tract infection testing was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing provided on October 7, 2022.
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 the enrollee requires daily physician 
assessment, 6 hours of daily nursing care and low intensity rehab that is provided in an LTACH. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs 
can be met in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. Your needs can be met at a lower level of care such as skilled 
nursing facility (SNF), home with home health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical 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 IRF admission and services.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says you are receiving appropriate in-patient 
care and does not require transfer to an LTACH. 
 
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 that you appear 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 you require that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous.  
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you do not feel comfortable going back to 
your previous dentist. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 8, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS would be pivotal 
to monitor the enrollee's pulmonary artery pressure routinely to avoid any acute symptoms that lead to inpatient 
admission The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMS device has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CardioMEMS device (33289).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that your balance is getting worse and that 
your functional ability and fall risk is also getting worse. You feel that your condition is limiting yourself by 
40%. You also state that you have difficulty walking on uneven ground and in the dark. The Plan denied your 
request. The Plan says this 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 there is no documentation provided with regards to treatment goals 
and outcome measures that the enrollee is objectively improving with therapy. Without this information, it 
cannot be determined if the required continued physical therapy is appropriate and effective. 
 
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 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation care discharge day management (procedure code 99217) 
rendered on August 10, 2022. 
 
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 that Current Procedural Terminology (CPT) code 99217 (1 unit) remains not supported. 
 
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 99217 is "Observation care discharge day management (This code is to be utilized to report all services 
provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than 
the initial date of "observation status." To report services to a patient designated as "observation status" or 
"inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services 
[including Admission and Discharge Services, 99234-99236 as appropriate.])." 
 
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 supported by the medical records. Our reviewer found that the documentation from 8/10/2022 
appears to be discharge day management, including an addendum indicating that transportation had been 
arranged. As there is no evidence of services or billing on the 8/11/2022, CPT 99217 on 8/10/2022 is 
supported. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
observation care discharge day management (procedure code 99217) rendered on August 10, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the enrollee has failed other alternatives and had side 
effects to others. The Plan denied your request. The Plan says Trulicity is on the self-administered drug list and 
is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  
 
  Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
29, 2022. 
 
You asked the Plan to pay for the billed services. You say that a notice of admission is not required. The Plan 
denied your request. The Plan says the type of bill submitted is incorrect. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim was not submitted with a type of bill suitable for payment. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from July 1, 
2022, to July 29, 2022.