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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
14-day reader device (E2103). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM reader device. You say that the enrollee has type 2 
diabetes and is not insulin treated. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested CGM device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre CGM reader device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 14-day reader device (E2103).
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 benefit from IRF level of care. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the brain. 
 
You asked the Plan to pre-approve a CT scan. You say that a CT scan is medically necessary. The Plan denied 
your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the preferred modality for the evaluation 
of memory problems would be magnetic resonance imaging (MRI) of the brain. There was no indication within 
the records provided for review that the enrollee has a contraindication to having an MRI. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the brain.
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 are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 an 
acute care hospital or a skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 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 pre-approve an office visit, a consultation and treatment (99204, 
99215, 57500) with a gynecology oncologist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit, a consultation and treatment with a specialist. You say that 
the biopsy is medically necessary for the enrollee. The Plan denied your request. The Plan says you must use 
in-network providers to receive services/care. This service is available by a provider in your network 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit, a consultation and treatment (99204, 99215, 57500) with a gynecology oncologist to be 
provided by an out-of-network (OON) provider.
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 doctor feels the enrollee will benefit from intense 
therapy. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not 
been met. 
 
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.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 enrollee has a commonly experienced deconditioned state following an acute 
stay. The enrollee is functioning at a skilled nursing facility level of care as she does not have intensive or 
complex rehabilitation needs. The enrollee does not require frequent physiatry oversight. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is not 
medically necessary because the records do not show nonunion of a fracture documented by a minimum of two 
sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a 
minimum of 90 days. 
 
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 ultrasonic osteogenesis stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a past medical history including a previous right tibia-
fibula fracture requiring surgical intervention on May 1, 2023. The documentation indicates the follow-up x-
rays have showed minimal bone callous formation with delayed healing. The most recent x-ray was not 90 days 
after initial fracture with surgical repair. According to Medicare, an ultrasonic osteogenesis stimulator can be 
covered as medically necessary when a nonunion of a fracture is documented by a minimum of two sets of 
radiographs obtained 90 days apart, and if the fracture is not of the skull or vertebrae and not tumor related. In 
this case, the documentation does not support that the enrollee has had two sets of radiographs with a 90-day 
interval that shows a lack of healing. The requested osteogenesis stimulator is not medically 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 an ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered to the enrollee from 
April 4, 2022, through May 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the remainder of the denied charges were denied for unbundling.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of the daily oxygen, this 
would be considered a routine charge, and would be included in the "room and board" charges. In terms of the 
venipuncture/specimen collection, this would not be reported separately during an inpatient hospital stay and 
would be included in the "room and board" charge. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered to the enrollee from April 4, 2022, through May 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has chronic pain over the past 13 years. Her condition has 
responded minimally to physical therapy, and she is able to do a home exercise program. She does not require 
continued input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressors (E0651, E0652) and segmental 
pneumatic appliances for use with pneumatic compressor, full leg (E0667, E0671) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compressors and appliances. You say that the enrollee has a 
long-standing relationship with the requested supplier achieving success in both the treatment of lymphedema 
and would healing. The Plan denied your request. The Plan says you must use in-network providers to receive 
services/care. These items are available by a provider/supplier in your network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compressors (E0651, E0652) and segmental pneumatic appliances for use with pneumatic 
compressor, full leg (E0667, E0671) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services provided on 
October 5, 2022, to October 24, 2022.  
 
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that the medical records 
provided support that the services in dispute were medically necessary.  The Plan denied your request. The Plan 
says the clinical information supports that the enrollee was not posing risk of imminent harm to self or others. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital 
services. Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on September 26, 2022, with Major 
Depressive Disorder, Recurrent Episode, Severe without Psychotic Features. Based upon review the records 
provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in 
question as he was not showing any dangerousness to self or others but did have passive suicidal thoughts. He 
had no auditory or visual hallucinations and was without aggressive behaviors while not showing any acute 
threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question. He had no auditory 
or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment 
beyond the dates in question as noted above as he was not a danger to himself or others and did not have any 
delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the 
date in question. It did not appear that the services for the dates in question were reasonably expected or 
medically necessary to improve the enrollees condition or for the purpose of diagnosis. The enrollee does not 
meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of 
October 5, 2022, forward and could have been treated in a less restrictive setting. He had no auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression. The enrollee was being cooperative 
and compliant while not showing any acute threats to safety. 
 
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 inpatient psychiatric hospital services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric hospital services provided on October 
5, 2022, to October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units of infectious agent detection by nucleic acid (87798) 
billed for date of service December 20, 2022.  
 
You asked the Plan to pay for 13 units of code 87798. You say that the records provided support the code as 
billed.  The Plan denied your request. The Plan says the records do not support 13 units of code 87798. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
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 13 units of code 87798. Our reviewer says that the criteria 
for coverage have not been met.  Our reviewer found medical documentation shows there is a higher specificity 
code that can be used in exchange for the 13 units of 87798. Medical records do not support procedure code 
87798. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 13 units of code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for 13 units of infectious agent detection by nucleic acid (87798) billed for date of service 
December 20, 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 will benefit from acute inpatients 
rehabilitation that cannot be accomplished at a lower level of care. 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.