Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that more than 28 treatments exceed the enrollee's need.  
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on standard medical necessity criteria, 45 fractions of IMRT would be within 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT).  
 
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 admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee does not meet all the requirements. The Plan says that 
the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 the enrollee meets the medical management criteria 
and need for physician oversight of therapy and medical needs. The Plan denied your request. The Plan says 
based on a review of the notes the enrollee is significantly de-conditioned and would not be able to tolerate 3 
hours of therapy daily, 5 days a week. 
 
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's documentation does not support that required 
intensive therapy for 3 hours a day at least 5 days per week and that care is too complex to be provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that the enrollee has met all appropriate home health physical therapy goals and given 
home exercise plan thus the records do not show that skilled physical therapy services would be required in the 
home setting to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy.
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 fell, hurt her head and also fractured T12 on 
your spine and is in a body brace. You are in pain, need approval for inpatient because you live with you 
husband who is elderly and wouldn't be able to care for you. The Plan denied your request. The Plan says you 
do not require medical supervision by a rehabilitation physician at least three (3) times weekly. 
 
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. 
 
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 image-guided intensity modulated radiation therapy 
(IG-IMRT) services. 
 
You asked the Plan to pre-approve the IG-IMRT services. You say that the records provided support the need 
for IG-IMRT. The Plan denied your request. The Plan says bladder cancer is not a covered indication for 
IMRT, as the data and evidence of IMRT in bladder cancer is lacking.  
 
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 IG-IMRT services. Our reviewer 
says that the IG-IMRT services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no comparison plan provided. The medical records do not offer an 
explanation or offer a quantifiable rationale for why IMRT is needed for this enrollee. No specific information about a 3D conformal plan being unacceptable was provided. While image-guided (IG) radiation is the 
standard of care when treating bladder cancer (even for palliative intent), image-guidance specifically for 
IMRT is not supported in this case.   
 
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 IG-IMRT services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve image-guided intensity modulated radiation therapy (IG-IMRT) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dayspring Active Compression System (K1024) and garment 
(K1033) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Dayspring Active Compression System and garment. You say that the 
requested OON provider is the only manufacturer and the sole provider of the Dayspring Active Compression 
System. The Plan denied your request. The Plan says that the requested provider is OON with the enrollee's 
plan. The Plan also says that this request is denied as investigational/experimental. 
 
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 Dayspring Active Compression 
System and garment. Our reviewer says that the requested durable medical equipment is considered medically 
reasonable and necessary to be rendered by an OON provider in this case. Our physician reviewer found the 
enrollee has persistent lower extremity edema despite measure to address it. Our reviewer also found that 
results of clinical evaluation suggest that the Dayspring System active compression system is safe and 
effective, and improves quality of life and limb volume.  
 
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 Dayspring Active Compression System and garment have been met. 
Therefore, we decided that the Plan has to pre-approve a Dayspring Active Compression System (K1024) and 
garment (K1033) to be rendered by an out-of-network (OON) provider.  
 
  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: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography (93460). 
 
You asked the Plan to pre-approve the outpatient service. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show that the requested service is 
needed to evaluate your heart prior to valve surgery. 
 
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 outpatient service. Our reviewer 
says that the requested catheter placement for coronary angiography is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation shows a radionuclide stress 
test in 2022 was negative for ischemia. The reviewer found that the records provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. Therefore, the reviewer found that the catheter placement 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 the outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography (93460).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for  the radiologic examination, ankle (73600) and radiologic examination, 
foot (73630) provided September 22, 2023. 
 
You asked the Plan to pay for  the diagnostic services. You say that the claim denied indicating the enrollee has 
Veterans Administration benefits in error. The services are not a duplicate and the enrollee does not have 
Veterans Administration benefits.  The Plan denied your request. The Plan says that the enrollee has Veteran 
status. Medicare does not cover services for Veteran Affairs hospitals, medical centers or administration 
hospitals. Send the claim to Veterans Health Plan. 
 
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. The Plan has not provided any information confirming that the enrollee has 
Veterans Administration (VA) status. The Plan has not provided any Veterans Administration details or that 
there was an attempt in coordination of benefits. In this case the Plan has not substantiated their reason to 
continue to deny. Therefore, we decided that the Plan has to pay for  the radiologic examination, ankle (73600) 
and radiologic examination, foot (73630) provided September 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has adequate upper body strength to control 
standard power drives.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
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 has multiple comorbidities including 
seizure disorder, that further complicate status, making a perfect candidate for inpatient rehabilitation. The Plan 
denied your request. The Plan says the enrollee's records do not show the rehabilitation needs are complex. The 
Plan says that the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 pay for inpatient services performed on December 10, 2022, and 
December 11, 2022, at DRG level 196. 
 
You asked the Plan to pay for the inpatient services. You say that the inpatient services should be covered 
under DRG level 196 because they were fully approved. The Plan denied your request. The Plan says no 
records to justify payment for the inpatient services under DRG level 196 were provided, despite requesting 
them multiple times. The initial authorization obtained by the provider was for observational care only. 
 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. In this case, we were able to confirm that the initial authorization 
obtained by the provider was for observational care only and not for an inpatient stay. No records documenting 
the inpatient services were provided. The Plan documented multiple attempts to obtain the necessary records, 
but no medical records were received. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient services have been met. 
Therefore, we decided that the Plan does not have to pay for inpatient services performed on December 10, 
2022, and December 11, 2022, at diagnosis-related group (DRG) level 196.
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 is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the records received do not show that the enrollee needs a 
physician to monitor care at least three days per week. The Plan says that the services needed may be provided 
safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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.