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 enrollee would benefit from short term 
rehabilitation to improve functional mobility, activities of daily living and gait to facilitate a safe return home 
and reduce caregiver burden. The Plan denied your request. The Plan says 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 enrollee has very low endurance likely related to prior impaired function and 
COVID-19. The record indicates are quite clearly showing that the enrollee cannot tolerate intensive 
rehabilitation. For a post-acute deconditioned state, there is little evidence that intensive rehabilitation is 
indicated, even if the enrollee could actually tolerate it. There are no complex requiring frequent physiatry 
oversight. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 12, 2022 to January 15, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
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 the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
based on the medical records provided, there is no documentation that the patient required (or received) skilled 
nursing services from 01/12/2022 through 01/15/2022.  The records did not document the need for intravenous 
medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. No skilled 
therapy services were documented in the records provided for the time period in question. Daily skilled 
services were not required. The enrollee did not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the nursing facility appear custodial. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from January 12, 2022 to 
January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
January 24, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining prior authorization for all their patients, which should also cover for medical 
treatments provided by this physician. The Plan denied your request. The Plan says the available case 
documentation and medical records were reviewed by a Plan Medical Director, and it was determined the 
services were not urgent or emergent. It was also determined the services rendered could have been provided 
by a participating provider under the members Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a semi-electric hospital bed provided on February 11, 2022. 
 
You asked the Plan to pay for hospital bed. You say that your doctor made the decision to have you placed in a 
hospital bed upon return home from the hospital. The Plan denied your request. The Plan says that the denial of 
payment for this item is correct, because the hospital bed was not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
This hospital bed was supplied by a contracted provider. The file does not show that the Plan provided notice 
that hospital bed would not be covered. Under Medicare rules, this means hospital bed is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for a semi-electric hospital bed provided on 
February 11, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from January 31, 2022, through March 1, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient skilled nursing facility care 
provided was 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 pay for the SNF care. Our reviewer says that the 
skilled nursing facility care provided was not medically necessary. Our physician reviewer found that the 
enrollee did not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical 
matter, the enrollee did 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from January 31, 2022, through  
March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment services provided on March 21, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation treatment services. You say that you were referred to this provider by 
one of the Plan doctors for radiation treatment. You also say that you would not have gone there if you did not 
think it was authorized. The Plan denied your request. The Plan says this provider is not a contracted provider. 
The Plan also says that there are many contracted providers in the area for radiation oncology that are familiar 
with Plan benefits, including the prior authorization requirements for radiation oncology. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for radiation treatment services provided on March 
21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy provided on March 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for radiation therapy. You say that you were referred to this provider by one of the 
Plan doctors for radiation treatment. You also say that you would not have gone there if they did not think it 
was authorized. The Plan denied your request. The Plan says this provider is not a contracted provider. The 
Plan also says that there are many contracted providers in the area for radiation oncology that are familiar with 
plan benefits, including the prior authorization requirements for radiation oncology. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for radiation therapy provided on March 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 1, 
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 the records do not include a lab order/requisition of 22 or more drug classes which is required to 
bill for the service provided. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code 
G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
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 supplied medical records do 
not support that 22 or more drug classes were tested in this case. 
 
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 drug testing services provided to the enrollee on March 1, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 that there are no complex or intensive rehabilitation needs. You are chronically 
deconditioned with further deterioration secondary to acute illness. There are no complex needs, and you do not need intensive rehabilitation to regain function for your post-acute deconditioned state. There is no 
indication for frequent physiatry oversight. The physical therapist noted that you could be managed at the 
skilled nursing facility (SNF) level. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of recurrent 
urinary tract infection and is living at home with complaints of weakness. The enrollees medical problems are 
stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental payment for an oxygen concentrator. 
 
You asked the Plan to pre-approve continued rental payment for an oxygen concentrator. You say that this is 
medically necessary. The Plan denied your request. The Plan says that this benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made.  
 
We looked at the file and Medicare rules. The file indicates that 36 rental payments have been made for your 
oxygen concentrator. Based on this information, we decided that Medicare rules for coverage of continued 
rental payment for an oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued rental payment for an oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 12, 
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 it is unable to be determined which drugs were tested. 
 
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 Healthcare Common Procedure Coding System code G0483 is 
"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, our reviewer found that that 
there is no documentation verifying that 22 or more drug classes were tested in this case. 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 drug testing services provided to the enrollee on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 transurethral waterjet ablation of 
prostate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have developed acute urinary retention in August 
2021. You have been able to void successfully since taking tamsulosin and finasteride. Your International 
Prostate Symptom Score (IPSS) is now four. Your prostate size is 118 cc by ultrasound. Post void residual is 32 
cc. Transurethral waterjet ablation of prostate is not medically reasonable and necessary in this case. You 
continue to have excellent results and no side effects with medical management. Also, the procedure is not 
recommended for prostate glands greater than 80 cc in size. Therefore, you do not meet criteria for the 
requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental of a negative pressure wound therapy 
pump. 
 
You asked the Plan to pre-approve continued rental of a negative pressure wound therapy pump. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy pumps are only 
covered for four months. 
 
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 rental of a negative pressure 
wound therapy pump. Our reviewer says that the documentation does not support that the requested device is 
medically reasonable or necessary. Our physician reviewer found the documentation of the change in wound 
dimensions over time showed that the wound was not improving but was getting large. In addition, Medicare 
will only authorize wound vacs for a total of a four month treatment period, regardless of progress or lack 
thereof in wound healing. Therefore, because the wound has not appreciably improved and you have reached 
the four month maximum, you do not meet criteria for the requested continued rental of a negative pressure 
wound therapy pump. 
 
 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 rental of a negative pressure wound therapy pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued rental of a negative pressure 
wound therapy pump.