Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant care services. 
 
You asked the Plan to pre-approve attendant care. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says this service is considered custodial care and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of attendant care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant care 
services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 You asked the Plan to pre-approve Avastin. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the step therapy requirements have not 
been met.  
 
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 Avastin. Our reviewer says that Avastin 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the required 
drugs Mvasi and Zirabev. Also, there is no documentation indicating that the Plan's required drugs would likely 
be less effective or likely have adverse effects 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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 8, 2022, to 
February 28, 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 secondary diagnosis code G93.41, described as 
Metabolic encephalopathy. 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 74-year-old female who was treated in the hospital. The 
documentation describes the enrollee as reporting abdominal pain and was found to have a urinary tract 
infection and acute kidney injury after workup. Also, Glasgow Coma Scale was assessed as 14 then later 15 a 
few hours later after initial treatment with fluids and antibiotics. Throughout the rest of the course of 
hospitalization, the enrollee was documented as alert and oriented, and she was at her baseline. Therefore, 
documentation does not sufficiently support the diagnosis code, G93.41for this admission.   
 
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 February 8, 2022, to February 28, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 the enrollee's needs can be met 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 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: 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 due 
to the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression wraps (A6545 x4) provided on 
November 30, 2022. 
 You asked the Plan to pay for the gradient compression wraps. You say that the gradient compression wraps 
were medically necessary. The Plan denied your request. The Plan says there is no documentation that the 
enrollee has a qualifying wound requiring treatment. The Plan also says that the requested gradient 
compression stockings are therefore statutorily non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that claims for gradient compression wraps used without a 
qualifying wound or when used for other non-qualifying conditions will be denied as statutorily non-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 pay for the gradient compression wraps. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does 
not have a qualifying wound requiring treatment. Therefore, the requested gradient compression stockings are 
statutorily non-covered. 
 
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 gradient compression wraps have not been met. Therefore, we decided that 
the Plan does not have to pay for the gradient compression wraps (A6545 x4) provided on November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can thrive in an acute inpatient 
rehabilitation environment that encourages recovery and independence. The Plan denied your request. The Plan 
says an IRF admission is not 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 that the enrollees 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 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 for the enrollee 
to receive a higher level of care and rehab services. The Plan denied your request. The Plan says the enrollee 
does not meet the 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exam provided on January 12, 
2023. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that it was a routine hearing exam. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for hearing services. 
 
You have been asked to pay a $40 copayment for the hearing exam. This item/service falls within the hearing 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hearing exam provided 
on January 12, 2023.
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 the enrollee does not have complex nursing, medical management, and 
rehabilitation needs that cannot be met at a less intensive 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a multi-disciplinary 
approach to help manage their multiple medical and physical complex issues. The Plan denied your request. 
The Plan says an LTACH is not medically necessary, and the enrollee's needs can be met in the current hospital 
setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 26 physical therapy visits and 16 skilled nursing 
services. 
 You asked the Plan to pre-approve home health services. You say that you are in pain and need help walking 
up the stairs. 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 that the 
enrollee does not have documented skilled nursing needs (IVs, complex wound care, and new ostomy). The 
enrollee does not have documented skilled physical therapy needs. As such, the requested, ongoing, home 
health skilled nursing and home health physical therapy services are not medically necessary or reasonable. 
 
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 26 physical therapy visits and 16 skilled nursing 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 needs rehab to regain their mobility 
before returning home. The Plan denied your request. The Plan says the enrollee does not meet the 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612), arthrodesis, posterior or posterolateral technique, single interspace; each additional 
interspace (22614), laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 
facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar (63030). 
   
You asked the Plan to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar, 
arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace, laminotomy 
(hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disc; 1 interspace, lumbar. You say that this is medically necessary. The 
Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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, posterior or posterolateral 
technique, single interspace; lumbar, arthrodesis, posterior or posterolateral technique, single interspace; each 
additional interspace, laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 
facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar. 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 evidence of spinal instability, fracture, or lesion. Also, interspinous 
process devices are experimental. Fusion is not needed. 
 
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, posterior or posterolateral technique, single interspace; lumbar, 
arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace, laminotomy 
(hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disc; 1 interspace, lumbar have not been met. Therefore, we decided that 
the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; 
lumbar (22612), arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace 
(22614), laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar (63030).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations at C2-3, C3-4, and C4-5. 
 
You asked the Plan to pre-approve radiofrequency ablations. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for radiofrequency ablations have 
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 radiofrequency ablations. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding at which levels the previous 
procedure was performed. Additionally, the enrollee is noted to have had two medial branch blocks; however, 
documentation is not clear that she had greater than 80% relief with those medial branch blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablations at C2-3, C3-4, and C4-5.