Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intra-Dialytic Parenteral Nutrition (IDPN) (B4197, 
B4185, B4189, B4193). 
 
You asked the Plan to pre-approve parenteral nutrition. You say that it is medically necessary. The Plan denied 
your request. The Plan says there was no documentation of permanent GI impairment. The enrollee has not 
tried enteral nutrition, so it has not been found to be ineffective. 
 
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 parenteral nutrition. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee is requesting approval for IDPN due to low 
albumin, poor appetite, and poor oral intake. The notes indicate that the enrollee has not tried the oral 
supplements that were recommended. Parenteral nutrition is considered reasonable and necessary when the 
treating practitioner documents that enteral nutrition has been considered and ruled out, tried and been found 
ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The review has determined that the 
enrollee does not meet criteria for the requested service. The requested parenteral nutrition is not  medically 
necessary 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 parenteral nutrition have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intra-Dialytic Parenteral Nutrition (IDPN) (B4197, B4185, B4189, B4193).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for admission to 
an IRF and will benefit from IRF care in a way that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says  the enrollee does not meet 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may a need for physical therapy 
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. 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. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service February 20, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided for the service 
performed. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. The medical records provided do not include a critical care note for the date of service at 
issue. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of 
service February 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 1, 2022, 
to November 16, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be reprocessed for 
payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 30, 2022. The NOA was not received by the Plan until 
December 7, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from November 1, 2022, to November 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic services on March 27, 
2023.  
 
You asked the Plan to waive the copayment for outpatient diagnostic services. You say that you shouldn't have 
to pay additional copayments. 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 $30 
copayment for Medicare-covered diagnostic procedures and tests. Covered services include but are not limited 
to other outpatient diagnostic tests. The provider billed in the amount of $18 and the allowed amount is $7.84. 
There were two services. 2 x $7.84 = $15.68. This is less than the copayment amount. Therefore, results in the 
total cost sharing amount of $15.68. You have been asked to pay a $7.84 copayment, which is less than the copayment for each outpatient 
diagnostic service. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies 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 outpatient diagnostic 
services on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee has been stuck in a 
nursing home due to severity of the bed malfunction and the bed totality, causing him harm of his safety. The 
current bed collapsed. The enrollee needs a new bed so he can come home from the nursing home. The Plan 
denied your request. The Plan says the request is not medically necessary as the height adjustment feature is a 
convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary must 
furnish sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. The medical records from the treating physician does not show the 
testing was ordered to treat a specific medical problem. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 has chronic respiratory insufficiency. She is however at stand by assist 
for mobility and contact guard assist for ambulation. Per chapter 1, the enrollee is functioning at a home care 
level. She is able to improve with repetitive exercise. She has no complex or intensive rehabilitation needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the infectious agent detection by nucleic acid (DNA or 
RNA) 12-25 targets (87507) provided January 19, 2023. 
 
You asked the Plan to pay for  the laboratory service. You say that please reprocess and pay on the entire claim. 
The Plan denied your request. The Plan says under Medicare guidelines, this request is not medically necessary 
because the records show the enrollee does not have an immunocompromising condition.   
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the covered indications as provided for the PCR stool panel under review, are 
appropriate to the enrollees GIP assay of 22 pathogen targets are medically reasonable and necessary for the 
evaluation of Medicare beneficiaries with the following an immunocompromising medical condition with acute 
or persistent diarrhea. No records were provided to support that the enrollee is immunocompromised. 
Commercial stool panels are widely available (1-4) for the convenience of stool pathogen testing by providers 
and their patients. While validated (5-7), these panels are however often overreaching and overly broad, and 
not medically appropriate nor necessary per provided criteria in the enrollees 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for  the infectious agent detection by nucleic acid (DNA or RNA) 12-25 targets (87507) 
provided January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA). 
 
You asked the Plan to pre-approve an MRA. You say that an MRA is medically necessary. The Plan denied 
your request. The Plan says that the requested MRA does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  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 MRA. Our reviewer says that an 
MRA is not considered medically necessary in this case. Our physician reviewer found that during the last 
encounter of May 17, 2023, there is mention of a normal brain computed tomography report but plans for a 
carotid ultrasound to be done May 22, 2023. There is no report. Likewise there is a stated plan for a stat 
magnetic resonance imaging of the brain due to declining mini-mental status exam (MMSE) but no report of 
same is in the chart. There is no history of nystagmus or focal neurological deficit and no history to imply 
aneurysm. The medical necessity of the requested MRA of the brain has not been established in the submitted 
records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MRA.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the hospital cannot provide the intense therapy you 
need. You also say denial of the requested IRF services will deteriorate your condition. The Plan denied your 
request. The Plan says the IRF services requested 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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. 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. 
 
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 an IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet the Medicare criteria for SNF care. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that a Barostim Neo device is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a Barostim Neo device is 
experimental/investigational. 
 
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 Barostim Neo device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
 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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a Barostim Neo device (0266T, C1825).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee flexion feature (L5845) for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve a knee flexion feature. You say that the requested feature is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that a knee flexion feature is not 
medically necessary because the previously approved prosthetic knee already has the feature requested. 
 
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 a knee flexion feature. Our reviewer 
says that the requested item is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the previously approved prosthesis feature L5812 does not contain the stance flexion 
feature denoted by code L5845. The classic function of a Safety Knee is to stop all flexion when the knee is put 
under any significant amount of weight, whereas adjustable stance flexion is a feature that permits a certain 
amount of knee flexion even under weight, up to a pre-set limit in the knee. The medical records are 
sufficiently detailed to explain the reasonableness and medical necessity of the treatment regime requested. 
 
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 knee flexion feature have been met. Therefore, we decided that the Plan has to 
pre-approve a knee flexion feature (L5845) for a lower-limb prosthesis.  
 
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 you are requesting an expedited reconsideration as 
the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the IRF 
services requested 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at a lower 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.