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 is in need of inpatient rehabilitation, and 
you believe the skilled nursing facility is not equipped to handle the level of care needed for medical and safety 
reasons. 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says you need therapy, but it appears that you can get the care you need at a 
lower level such as in a 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 the enrollee does not require treatment by multiple therapies. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on November 12, 2022, billed with code 
74177-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that that the required modifier for this procedure 
code is missing. 
 
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. We find that the specific denial rational offered by the plan is not supported. The 
plan states that the patient status listed on the claim indicates that the patient was in custody when the services 
were provided and are not payable unless billed with a valid modifier. The plan has not provided actual 
evidence that the enrollee was listed in custody on the date the services were provided. Therefore, we decided 
that the Plan has to pay for radiological services provided on November 12, 2022, billed with code 74177-26.  
 
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 Nucynta. 
 
You asked the Plan to pre-approve Nucynta. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
 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 Nucynta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not 
show a threat to self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 Continued inpatient care from June 8, 2023, forward was requested. 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 services. Our physician reviewer found that you were admitted to 
inpatient care with schizoaffective disorder, bipolar type. It was not expected you would improve in a 
reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or 
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats 
of safety. You did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal 
behaviors. The services in question were not reasonably expected or medically necessary to improve your 
condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria 
for treatment in an acute inpatient mental health treatment beyond the date in question. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 23, 2022, to 
May 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as Sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found the enrollee is a 78-year-old female who presented to the emergency department 
with worsening weakness, sinus congestion, fever/chills, and fatigue for one week even after starting antibiotics 
as outpatient. On workup she had a fever, diffuse expiratory rales, elevated procalcitonin, creatinine 1.48, 
Oxygen saturation 90-94%. She was diagnosed with pneumonia based on imaging and clinical signs and started 
on fluids and antibiotics. Following initial fluids/antibiotics creatinine dropped to 1.1 over two days. Bilirubin 
and platelets were normal. She was alert and oriented x 3 on examination. Sepsis 3 criteria was not met. 
Creatinine was elevated, might be considered a SOFA of 1, but it resolved with initial treatment rather than 
worsen. There was no other evidence of organ failure resulting from a dysregulated response to systemic 
infection. Therefore, the sepsis code, A41.9, is not sufficiently supported in the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 23, 2022, to May 26, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0637). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you need the lift mechanism to be able 
to go home and to be able to get in and out of bed. The Plan denied your request. The Plan says the requested 
item (Sara Lift) is specifically listed as not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that some items may not meet the definition of a 
Medicare benefit or may be statutorily excluded. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-
approve a seat lift mechanism (E0637).
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission stating the enrollee's condition has stabilized, and they 
will require a multi-disciplinary approach for an extended period of time. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee appears to be improving and should only require short-term 
additional acute care that can safely be provided at the current facility until more appropriate for a lower level 
of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH would not be clinically advantageous and 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 long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says you have not tried the 
preferred drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our physician reviewer found 
that you have a history of ulcerative colitis. The Plan requires a trial of Stelara before they will approve the 
requested drug. In this case, you have not tried and failed the required drug. There is no documentation 
provided indicating that the Plans required drug would likely be less effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
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 the services are medically necessary for 
the enrollee to receive the care needed to prevent the loss of their foot. The Plan denied your request. The Plan 
says the enrollee can safely receive this care in another setting, such as a skilled nursing facility.  
 
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 the enrollee appears to be improving and should only require short-term additional 
acute care that can safely be provided at the current facility until more appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 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 long term acute care hospital (LTACH) 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 the enrollee requires the rehabilitation services to 
return to prior level of function, return home safely and maximize independence. The Plan denied your request. 
The Plan says the enrollee can reasonably be expected to continue your recovery at a lower level of care with 
good success.  
 
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 clinical documentation shows that the enrollee requires ongoing physical and 
occupational therapy, however it does not show that the enrollee requires an intensive rehabilitation regimen in 
an IRF 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: 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 you are requesting an expedited 
reconsideration stating the enrollee requires an LTACH level of care and is stable for discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to be improving and should only require short-term 
additional acute care that can safely be provided at the current facility until more appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH would not be clinically advantageous and 
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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's current medication is being given 
at the maximum dose. You also say that the current medication is not adequately managing the enrollee's 
glucose levels. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 Ozempic.  
 
Benefits for the medication 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: 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 still needs SNF care, and you are unsure 
why it was canceled. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low air loss mattress. 
 
You asked the Plan to pre-approve a mattress. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for a mattress. 
 
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 a mattress. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case do not document the enrollee has multiple stage 2 pressure 
ulcers located on the trunk or pelvis or the enrollee has large or multiple stage 3 or 4 pressure ulcer(s) on the 
trunk or pelvis or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days as required by the Local Coverage Determination (LCD) Pressure Reducing Support Surfaces 
- Group 2 L33642. Based on the medical records provided there is no documentation that the group 2 support 
surface at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low air loss mattress.