Persius/hicric huggingface dataset:
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 enrollees needs physical and 
occupational therapy so they can return home at their baseline. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's needs can be met in another 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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. 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. 
 
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: Surgery
Decision: Partially Favorable

 
You asked the Plan to pre-approve a varicose vein treatment procedure.. You say that these services are 
medically necessary. The Plan says that coverage criteria has not been met. 
 
We decided that the Plan has to pre-approve stab phlebectomy of the tributary veins on the right.  
 
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 varicose vein treatment procedures. 
Our reviewer says that part of this procedure is medically necessary.  Our physician reviewer found the right lower extremity stab phlebectomy is medically necessary as there is 
sufficient documentation of vein size.  
 
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 part of the procedure have been met. Therefore, we decided that the Plan 
has to pre-approve stab phlebectomy of the tributary veins on the right.  
 
We also decided that the Plan does not have to pre-approve ablation of the small saphenous vein on the 
left. 
 
Our reviewer says that this part of the request is not medically necessary. Our physician reviewer found that 
many patients experience sufficient improvement in their symptoms with the saphenous ablation alone. To be 
considered medically necessary for stab phlebectomy, the patient would need to demonstrate continued 
lifestyle limiting symptoms despite conservative treatment including regular use of compression stockings, for 
a period of 6 weeks following the stab avulsion. 
 
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 part of the procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ablation of the small saphenous vein on the left. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the new patient outpatient office visit (99203). 
 
You asked the Plan to pre-approve the office visit. You say that you are appealing the denial for an ENT 
consultation. The Plan denied your request. The Plan says that the records do not show that the referral meets 
the criteria for an ENT consultation at this time. 
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is documentation that the ear nose and throat 
(ENT) evaluation at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
enrollee. The provided records in this case document otalgia, sore throat, phlegm and dizziness. The enrollee 
obviously has some history of sensory neural hearing loss as is wearing hearing aids. Without performing an 
indirect mirror examination or direct flexible laryngoscopy, adequate evaluation of the larynx and hypopharynx 
is not possible. Referred otalgia can be a symptom of oropharyngeal, hypopharyngeal and laryngeal pathology. 
The enrollee is a former smoker and current alcohol user which may increase the risk for some head and neck 
pathology. There is no documentation of a prior ENT evaluation for the enrollees symptoms. Evaluation of 
symptoms with an ENT evaluation meets Medicare/Social Security Act, Section 1862(a)1(A) criteria for 
medically reasonable and 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 office visit have not been met. Therefore, we decided that the Plan has to 
pre-approve the new patient outpatient office visit (99203).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve removal and replacement of phrenic nerve stimulation system 
(0431T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that denial of this procedure is unwarranted 
and unsupported by the enrollee's current medical status and is inconsistent with currently accepted medical 
practice. The Plan denied your request. The Plan says that the requested phrenic nerve stimulator (PNS) is 
considered investigational and experimental and therefore not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the surgical procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of chronic fatigue, lack of energy, 
excessive daytime sleepiness, depression irritability and nighttime gasping. Reevaluation for central sleep 
apnea treated with epicardia phrenic nerve stimulator and doing very well. The enrollee is able to get restful 
sleep and feels much better. In this case, phrenic nerve stimulation has proved beneficial in the treatment of the 
enrollee's central sleep apnea (CSA) condition. The review has determined that the items/services at issue in 
this case is medically reasonable and 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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pre-approve removal and replacement of phrenic nerve stimulation system (0431T).  
 
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: 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 if you do not get proper rehabilitation, you will not 
be able to walk again if your leg becomes stiff. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs are currently being met at the current skilled nursing facility. 
 
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 to an acute hospital after a fall sustaining left hip fracture and 
underwent surgery. You are medically stable at the skilled nursing facility with no documented acute events. 
There are no acute rehabilitation nursing needs identified or documented. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a tertiary-level pain management provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary and care can be provided by the in-
network, non-tertiary provider. 
 
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 these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the enrollee has cervical 
myelopathy and radiculopathy. The records do not support that the enrollee's medical needs require the tertiary 
level of care. The plan has an in-network provider that is capable and able to provide services for the enrollee. 
The tertiary provider 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level pain management provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel you are a candidate for the SSBCI 
program. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is 
receiving the care needed in the current LTACH. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that there is documentation that the enrollee requires skilled nursing services. The records document the 
need for new tube feeding and complex respiratory care for ventilator weaning with moderate to large 
respiratory secretions. The enrollee does require skilled therapy services due to severe treatment. There is no 
documentation that daily skilled services are required. The provided records indicate only one physical therapy 
visit and one occupational therapy visit in the past five days and no recent speech therapy visits. The enrollees 
ability to participate in therapy is uncertain given his reported encephalopathy, lethargy and limited ability to 
follow commands. The enrollee is presently receiving appropriate services in the long-term acute care setting. 
It is not clear that the enrollee is stable to transfer out of the hospital setting. Continued care in the long-term 
acute hospital is appropriate until the enrollee is stable to transfer to a long-term care facility or until his mental 
status improves to be able to remove his restraints and for him to be able to participate with daily therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that it is less hassle for you to use this device. 
The Plan denied your request. The Plan says the request is not reasonable and medically necessary. 
 
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. There are no medical records to show that you 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 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service November 13, 2021. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the code as billed. The 
Plan denied your request. The Plan says code 99223 is not supported by the medical record because there is no 
evidence of a comprehensive history. 
 
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 99223 is initial hospital care evaluation and management 
of a patient that requires 3 key components.  The 3 key components are a comprehensive history, 
comprehensive examination and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the member is a 78-year-old male with a medical history 
including hypertension, atrial fibrillation, Parkinson's disease and cardiac disease who was admitted to the 
hospital on November 12, 2021, with chest pain. He was noted to be a poor historian due to dementia. He was 
diagnosed with atrial fibrillation with rapid ventricular response and unstable angina. There is no 
documentation from November 13, 2021, to indicate the medical decision was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service November 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS devic. You say that this procedure 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 CardioMEMS devic. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient 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 the CardioMEMS devic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria. 
 
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. In this case, there are no medical records that show the enrollee uses 
insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the 
blood glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to 
their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections. 
 You asked the Plan to pre-approve the Synvisc injections. You say that these injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the 
patient has failed at least three months of conservative 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 Synvisc injections. Our reviewer 
says that the requested injections are not medically necessary. Our physician reviewer found the records do not 
show three months of conservative therapy has failed. 
 
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 Synvisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (LAAC). 
 
You asked the Plan to pre-approve Left Atrial Appendage Closure (LAAC). You say that the requested left 
atrial appendage exclusion is medically necessary. The provider says this procedure should be authorized 
because the enrollee has history of atrial fibrillation, and the surgery requires sternotomy therefore they would 
already have access to his atrial appendage and can easily place a clip. The Plan denied your request. The Plan 
says the procedure is 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 Left Atrial Appendage Closure 
(LAAC). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the medical necessity of implanting a LAAC 
device in this enrollee in whom there is elevated risk of thromboembolic stroke due to atrial fibrillation and 
elevated CHADS2VASC score. There is no apparent contraindication to anticoagulation. As such, guidelines 
would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be 
considered reasonable or medically necessary 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 Left Atrial Appendage Closure (LAAC) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (LAAC).