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 you have been hospitalized on and off for three 
months and needs help walking. You say you are experiencing weakness and are not independent. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care such as 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 you were admitted for congestive heart failure. Your medical problems are stable, 
and there are no complex nursing or rehabilitation needs. You do 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.  
 
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 pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 11, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
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 96521 is refilling and maintenance 
of portable pump. We find that code 96521 is not supported in the medical record. The records do not 
document the refilling and maintenance of a portable pump. 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 pay for 
the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 24, 2023. 
 
You asked the Plan to pay for the supply allowance for the CGM. You say that you have sent the 
documentation to support payment for the claim. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supply allowance for the CGM. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires insulin use or low blood sugars. This enrollee is not having low blood sugars that 
we are told of. Although the enrollee was advised to begin insulin, we are not told that this happened and that 
the enrollee is taking insulin. The enrollee is on a medication Glipizde, that can cause low blood sugars, but we 
are not told that the enrollee is having low blood sugars. If the enrollee begins insulin, the chart should be re-
reviewed. 
 
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 supply allowance for the CGM have not been met. Therefore, we decided 
that the Plan does not have to pay for the supply allowance for a continuous glucose monitor (CGM) provided 
by an out-of-network provider on July 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (27279), an allograft (20930), and an autograft (20936). 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device, an allograft, and an autograft. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 arthrodesis, sacroiliac joint, 
percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft 
when performed, and placement of transfixing device, an allograft, and an autograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability fracture or lesion. SI joint fusion is not medically needed. SI joint 
fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device, an allograft, and an autograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279), an allograft (20930), and an autograft (20936).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection, 1 mg (J7325). 
 
You asked the Plan to pre-approve the medication. You say that you are appealing the denial of coverage and 
the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan 
says the enrollee's condition does not represent a medically accepted indication for the drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Intra-articular injections with hyaluronic acid (Synvisc-One) are recommended as a possible 
option for severe osteoarthritis for patients who have not responded adequately to recommended conservative 
treatments (exercise, NSAIDs, and/or Acetaminophen) to potentially delay total knee replacement. However, in 
recent quality studies, the magnitude of improvement appears modest at best. While osteoarthritis of the knee is 
a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, 
chondromalacia patellae, osteochondritis dissecans, or patellofemoral syndrome (patellar knee pain).  Hyaluronic acids are naturally occurring substances in the body's connective tissues that cushion and lubricate 
the joints. Intra-articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee; there 
are significant improvements in pain and functional outcomes with few adverse events. The review has 
determined that the documentation does not support that the Synvisc-One is medically reasonable and 
necessary for the enrollee. The documentation does not support that the Synvisc-One, is safe and effective for 
the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg 
(J7325).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Esoguard test (0114U) provided on June 22, 2023. 
 
You asked the Plan to pay for Esoguard test. You say that this test was necessary and appropriate. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Esoguard test have not been met. Therefore, we decided that the Plan does not 
have to pay for Esoguard test (0114U) provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve functional neuromuscular stimulation. 
 
You asked the Plan to pre-approve functional neuromuscular stimulation. You say that you suffered a stroke 
eight years ago. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that functional neuromuscular stimulation is only covered 
for certain indications. 
 
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 functional neuromuscular stimulation. 
Our reviewer says that the documentation does not support that the requested services are not medically 
necessary. Our physician reviewer found you had a hemorrhagic stroke in 2015 with right sided hemiplegia 
affecting the non-dominant side and have mild speech deficiencies. The requested services are covered after 
completion of training program for walking will be covered in spinal cord injury (SCI) patients. The 
documentation does not support that the service is being used after completion of a training program for 
walking with a spinal cord injury. 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 functional neuromuscular stimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve functional neuromuscular stimulation.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation received does not 
support the need 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 that there is nothing from the record to suggest that the enrollee requires services that 
are not available at the hospital where they are currently receiving care. In addition, the enrollees treatment for 
superficial wound infection with intravenous cefepime will be completed, per infectious disease notes, by  November 30, 2023. Therefore, it is not expected that the enrolee will require inpatient level care for the length 
of time generally reserved for LTACH care (25 days). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 12, 2023, billed with 
procedure codes 93306, 93880, and 93925. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 93306, 93880, and 93925 is echocardiography, 
transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 
complete, with spectral doppler echocardiography, and with color flow doppler echocardiography, duplex scan 
of extracranial arteries; complete bilateral study, and duplex scan of lower extremity arteries or arterial bypass 
grafts; complete bilateral study.  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the billed procedures were not 
documented in interpretation report, and therefore cannot be verified. There is a more specific code that should 
be reported for documented services. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 12, 2023, billed with procedure codes 
93306, 93880, and 93925.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF is medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to 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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to 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 is not medically 
necessary as it would not be clinically advantageous at this time.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the emergency department (ED) services provided 
on July 4, 2023. 
 
You asked the Plan to waive the coinsurance for the ED services. You say that you were out of town, and it 
was a medical emergency for you to go to the emergency room. The Plan denied your request. The Plan says 
that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for emergency care.  
 
The Plan says you must pay a 20% coinsurance for the ED services. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the ED services. Therefore, we decided that the Plan has 
to waive the coinsurance for the emergency department (ED) services provided on July 4, 2023.  
 
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 your provider states you can receive medical 
management of your current needs and that you can be seen daily by a physician at the IRF, and reduce your 
risk of returning to the hospital. The Plan denied your request. The Plan says you do not meet all the 
requirements 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 the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
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.