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

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the request for an inpatient admission is being denied because the 
clinical information did not support the medical necessity for this service. The Plan states the enrollee's 
condition could be managed in an observation setting, with follow up testing as an outpatient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided documentation did not describe symptoms or signs of uremia, anuria, or other factors making dialysis urgent or complex to justify inpatient services related to this procedure. 
Therefore, inpatient admission is not medically necessary. Observation status would be more appropriate for 
this enrollee to receive dialysis based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650) and implantable neurostimulator electrode, each (L8680). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show the 
enrollee's doctor is planning to perform medial branch blocks to address their neck pain. 
 
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 physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures for the cervical spine. There is no surgical 
consultation noted to indicate the enrollee is not a surgical candidate. The stimulator would not be considered a 
late/last resort. Moreover, the exam from June 1, 2022, indicates the treatment plan is for medial branch blocks 
and not for a spinal cord stimulator. Therefore, the medical records provided do not meet the requirements 
listed in the NCD/LCD for Medicare coverage. 
 
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 percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) 
and implantable neurostimulator electrode, each (L8680).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the neck 
(70547), magnetic resonance imaging (MRI) of the pelvis (72197), and MRI of the spinal canal and contents 
(72148). 
 
You asked the Plan to pre-approve an MRA of the neck, and MRIs of the pelvis and spinal canal and contents. 
You say that you need the MRI's to be completed at the hospital while you are under intravenous sedation. The 
Plan denied your request. The Plan says the notes show you called in requesting to have an MRI of the neck, 
lower back and hip was not ordered by your doctor. The Plan also says that since this is not a service you can 
get without the order from your doctor, the request remains denied.  
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an MRA of the neck, and MRIs of the pelvis and spinal canal and contents have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of 
the neck (70547), magnetic resonance imaging (MRI) of the pelvis (72197), and MRI of the spinal canal and 
contents (72148).
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and do not require 
transfer to a 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 more stable and improving and should only require short-term 
additional acute care hospital services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. You do not require services at the LTACH that are not already available at 
the current facility. 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 at this time. Completion of treatment at the current facility is recommended.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the requested CGM is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for approval of the sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 2 sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Pembrolizuamb (Keytruda) is not FDA 
approved for the treatment of uterine carcinosarcoma. Off-label use in not supported by the NCCN guidelines, 
major drug compendia, or the medical literature for this setting. The service is not reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for twenty (20) additional routine transportation 
trips. 
 
You asked the Plan to provide coverage for twenty (20) additional routine transportation trips. You say that the 
additional transportation is necessary. The Plan denied your request. The Plan says your benefit only allows 60 
trips per year for this service. You currently have 1 trip remaining and you will have exceeded your benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit only 
covers up to 60 one-way trips each year and you have 1 trip remaining. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for twenty (20) additional routine transportation trips.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health skilled nursing services billed for dates of service April 
22, 2022, to May 18, 2022. 
 
You asked the Plan to pay for home health skilled nursing services. You say that you have submitted a Notice 
of Admission (NOA). The Plan denied your request. The Plan says that a valid NOA has not been submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied because the submitted NOA was filed under an 
incorrect Type of Bill (TOB) code. The case record does not document that an NOA was submitted with an 
incorrect TOB. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's 
denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay 
for home health skilled nursing services billed for dates of service April 22, 2022, to May 18, 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 Riluzole. 
 
You asked the Plan to pre-approve Riluzole. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says Riluzole is a self-administered drug and does not 
fall under Part B coverage. The Plan says that the enrollee does not have pharmacy benefits administered by 
them. 
 
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 Riluzole.  
 Benefits for Riluzole 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: 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 based on the enrollee's current function, his goal of 
returning home to his prior level of independence can be accomplished with three hours of intensive rehab. 
You say that the enrollee has interdisciplinary needs and acute active ongoing medical problems to require at 
least three face to face physician visits a week. The Plan denied your request. The Plan says the IRF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for twenty (20) additional routine transportation 
mileage. 
 
You asked the Plan to provide coverage for twenty (20) additional routine transportation mileage. You say that 
you need the additional mileage to go to a neurologist appointment. The Plan denied your request. The Plan 
says your benefit only allows 50 miles for each one-way trip. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for twenty (20) additional routine transportation mileage.
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 you're not ready to go home. The Plan 
denied your request. The Plan says admission to the IRF was denied as not meeting criteria, is not medically 
necessary, and a lower level of care might be appropriate. Home with supervision and home health care was 
offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you were admitted for perforation of the duodenum.  Medical problems are 
stable. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 11, 
2022, to May 10, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee did not receive daily skilled services during the dates of 
service in this case. 
 
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 pay for 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 the documentation provided does not support that the enrollee qualified for SNF 
coverage during the dates of service in this case. The reviewer found that the enrollee did not have documented 
skilled nursing needs.  The enrollee did not have documented skilled therapy needs. Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
Therefore, the reviewer found that the requested SNF care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 11, 2022, to May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee medical management and rehab needs 
require close physician supervision and IRF care. You say that IRF care is medically necessary for the enrollee 
to return home at their maximum level of functioning with a decreased risk for readmission. The Plan denied 
your request. The Plan says IRF is not medically necessary. The enrollee current acute conditions have not 
stabilized and, the enrollee is not ready to be moved on to the next level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical records support 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 IRF admission and services.