Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee will be safer in a skilled nursing facility 
and will become stronger there. The Plan denied your request. The Plan says the enrollee's records do not show 
that you require daily skilled services that can be provided only on an inpatient basis in a SNF. Services you 
require can safely be received at a different setting, at home with home health, in residential care, or home with 
close follow-up with your physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 cannot be managed in a sub-acute 
rehabilitation setting due to ongoing medical complexity. You say inpatient rehabilitation is in the best interest 
of the enrollee and their ongoing medical needs and care. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kyphoplasty (22514). 
 
You asked the Plan to pre-approve the Kyphoplasty. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Kyphoplasty. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there is no documnetation of an acute fracture. There is no trial of bracing. The patient also has 
spondylolisthesis and the cause of pain is not clear from the provided records. 
 
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 Kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of TheraSkin skin substitute. 
 
You asked the Plan to pre-approve TheraSkin skin substitute. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item 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 TheraSkin skin substitute. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case.  Our physician 
reviewer found that there is insufficient documentation of adequate circulation/oxygenation to support tissue 
growth and wound healing and adequate glycemic control. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of TheraSkin skin substitute.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medications provided for use in a pump on August 31, 
2022, billed with codes J0475 and J3010. 
 
You asked the Plan to pay for the medications as billed. You say that this should be paid as billed.  The Plan 
denied your request. The Plan says the compounded drugs were not correctly billed. 
 
The Plan must follow Medicare rules. Medicare rules say that compounded drugs used in a pump should be 
reported with code J7999KD. 
 
We looked at the file and Medicare rules. The drugs at issue were compounded for use in a pump. As such, the 
codes used are not appropriate. Based on this information, we decided that Medicare rules for coverage of the medications as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
medications provided for use in a pump on August 31, 2022, billed with codes J0475 and J3010.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 Physical Therapy (PT) visits. 
 
 
 
 You asked the Plan to pre-approve the PT visits. You say that you have been having some intense pain recently 
and are concerned that if you cannot continue the physical therapy treatment that you have been receiving, it 
could cause just days and weeks of immense pain. The Plan denied your request. The Plan says you should be 
able to transition to a home education program with the total approved visits.  
 
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 PT visits. 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 strength training is not a continuing skilled need. You are able to 
access the gym and continue with a home exercise program. Continued input from a skilled therapist is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 12 Physical Therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 78452, 93017 and A9502 billed for date of 
service June 9, 2022. 
 
You asked the Plan to pay for procedure codes 78452, 93017 and A9502. You say that the services at issue 
have been billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 78452, 93017 and 
A9502 have been met. Specifically, no medical records were provided to verify the procedure codes at issue. 
Therefore, we decided that the Plan does not have to pay for procedure codes 78452, 93017 and A9502 billed 
for date of service June 9, 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 the enrollee would benefit from inpatient acute 
rehabilitation to maximize function. The Plan denied your request. The Plan says the enrollee records do not 
show that rehabilitation needs are complex and the need to be seen 3 times per week for evaluation of 
functional and medical goals and progress. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the medical necessity criteria 
for admission to an IRF. 
 
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 your 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre -approve a continuous glucose monitor (CGM). You asked the Plan to pre -approve the CGM. You say that the enrollee can control their sugars with the use of 
the CGM. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre -approve a 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips (A0100). The Plan denied 
your request. The Plan says the evidence shows that you have used your allowed thirty-four (34) one-way trips 
of the thirty-four (34) one-way trips. 
 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. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
non-emergency transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided on August 23, 
2022. 
 
You asked the Plan to pay for presumptive drug testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says only one code from the 80305-
80307 code range may be reported per date of service. Code 80305 has already been reported for this enrollee 
for this date. 
 
The Plan must follow Medicare rules. Medicare rules say that only one code from the 80305-80307 code range 
may be reported per date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of presumptive drug testing have not been met. Specifically, the documentation supports that code 
80305 was also reported for this enrollee on the same date of service. Therefore, we decided that the Plan does 
not have to pay for presumptive drug testing (80307) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI).  
 
You asked the Plan to pre-approve a repeat TFESI. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says a repeat TFESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three 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 a repeat TFESI. Our reviewer says that 
the requested repeat TFESI is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee had 50% pain relief for at least three months. Therefore, the reviewer found that a repeat TFESI 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 a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI).
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 is medically stable and does not need rehabilitation physician 
supervision 3 times per week in an IRF. While the enrollee may benefit from physical therapy and occupational 
therapy, the enrollee's rehabilitation needs can be provided in a lower intensity 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 83521 and 85025 billed for date of 
service September 6, 2022. 
 
You asked the Plan to pay for procedure codes 80053, 83521 and 85025. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says the billed code is a statutory exclusion.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 80053, 83521 and 85025 have a Status Indicator of X on the Physician Fee 
Schedule. This means that procedure codes 80053, 83521 and 85025 are a statutory exclusion. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 80053, 83521 and 85025 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80053, 83521 and 
85025 billed for date of service September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
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. 
 
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 services are not medically necessary. Our physician reviewer found the Optimizer Smart device was 
approved by the Food and Drug Administration (FDA) in 2019 but remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. The services are therefore 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 an Optimizer Smart device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
bilateral pneumatic Leg sleeves (E0667). 
 
You asked the Plan to pre-approve a PCD and bilateral pneumatic Leg sleeves. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. The medical necessity determination for a PCD by the treating practitioner must include 
symptoms and objective findings, including measurements, to establish the severity of the condition.  
 
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 a PCD and bilateral pneumatic Leg 
sleeves. Our reviewer says that the items are not medically necessary. Our physician reviewer found the treating practitioner did not include symptoms and objective findings, including measurements, to establish the 
severity of the condition in the medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PCD and bilateral pneumatic Leg sleeves have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
bilateral pneumatic Leg sleeves (E0667).