Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to 
improve self-care functioning.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of January 5, 2024 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He 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 inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
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 need this care to regain independence before 
returning home. The Plan denied your request. The Plan says medical records do not support the need for an 
IRF admission and, your needs can be safely provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device, two lead, localized stimulation (E0720) and electrical stimulator supplies, 2 lead, per month (A4595). 
 
You asked the Plan to pre-approve a TENS device and supplies. You say that you need the requested device 
because you are in a lot of pain. You do not believe that in these times, this should happen. The Plan denied 
your request. The Plan says you do not meet criteria for approval of the TENS device. 
 
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 TENS device and supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a history of polyarthritis and morbid obesity. You describe an 8 
out of 10 for knee pain. Your provider has recommended pain management and physical therapy. The review 
has determined that you do not meet the coverage criteria for a TENS unit. 
 
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 TENS device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device, two lead, 
localized stimulation (E0720) and electrical stimulator supplies, 2 lead, per month (A4595).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional reimbursement for hospital care provided from 
May 16, 2023, to May 31, 2023. 
 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 claims are duplicates. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation provided supports that the provider was already reimbursed for CPT 99232 for the dates of 
service for the same provider. This appears to be a repeat or duplicate request for reimbursement for these 
dates. The documentation does not sufficiently support that the enrollee had seen separate doctors, with 
separate specialties, for unrelated problems, on each of the dates of service at issue 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional reimbursement for hospital care provided from May 16, 2023, to May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
gradient pressure pneumatic appliance (E0671). 
 
You asked the Plan to pre-approve a pneumatic compression device and segmental gradient pressure pneumatic 
appliance. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the 
request for a pneumatic compressor and accessories to be covered does not meet the requirements for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. Medicare rules also say if the base PCD is not 
covered, related accessories are not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental gradient pressure pneumatic appliance (E0671).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy with rotator cuff repair (29826, 
29827). 
 
You asked the Plan to pre-approve shoulder arthroscopy with rotator cuff repair. You say that this is medically 
necessary. The Plan denied your request. The Plan says records do not show that the enrollee has tried 
conservative treatment. This is 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 shoulder arthroscopy with rotator cuff 
repair. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Despite the noted 
magnetic resonance imaging of the right shoulder dated January 3, 2023, showing a full-thickness tear of the 
anterior and central insertional fibers of the supraspinatus tendon; there is no corroboration of retraction or 
muscle atrophy. The peer-reviewed literature supports conservative treatment for rotator cuff tears, even in full-
thickness tears (especially when she notes improvement in the shoulder on the November 15, 2023, 
examination since the previous examination on November 1, 2023.) There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder arthroscopy with rotator cuff repair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve shoulder arthroscopy with rotator cuff repair (29826, 
29827).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Prolia. 
 You asked the Plan to pre-approve the medication. You say that the requested drug is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and/or failed the 
preferred class of medications in bisphosphonates.  
 
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 the medication. Our reviewer says that 
the enrollee does not meet the criteria. Our physician reviewer found the clinical documentation does not 
contain the trial and failure of bisphosphonates by the enrollee. The documentation also does not support that 
bisphosphonates would likely be less effective, and/or would likely have adverse effects for the enrollee 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 medication. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection, anesthetic agent and/or steroid; other peripheral nerve or branch provided on June 14, 2022.

You asked the Plan to pay for the injection, anesthetic agent and/or steroid; other peripheral nerve or branch. You say that the injection, anesthetic agent and/or steroid; other peripheral nerve or branch was medically necessary. The Plan denied your request. The Plan says the use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that the use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the injection, anesthetic agent and/or steroid; other peripheral nerve or branch. Our reviewer says that the requested injection, anesthetic agent and/or steroid; other peripheral nerve or branch is not considered medically reasonable and necessary. Our physician reviewer found that the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases is insufficient. The procedure was not medically reasonable and 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 injection, anesthetic agent and/or steroid; other peripheral nerve or branch have not been met. Therefore, we decided that the Plan does not have to pay for an injection, anesthetic agent and/or steroid; other peripheral nerve or branch provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission and stay. 
 
You asked the Plan to pre-approve an inpatient admission and stay. The Plan denied your request. The Plan 
says the treatment requested does not meet criteria per standard of care or reviewer judgment. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 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 inpatient admission and stay. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission and stay are 
met in this case. Our physician reviewer found the patient presented with acute onset dizziness, tired, falling 
but not hitting head. Vitals were stable. Workup and examination revealed chronic anemia, pleural effusion, 
creatinine 2.74 (baseline 1.3) and abnormal echocardiogram. Our reviewer found that the patient was diagnosed 
with hypertrophic obstructive cardiomyopathy, congestive heart failure exacerbation, and acute kidney injury 
and was started on fluids, hold diuresis, and add Camzyos. However, the patient was not symptomatic in the 
emergency department and the plan was to hold diuresis and monitor kidney function with other plans being for 
chronic disease (Camzyos, septal myomectomy, coronary artery bypass graft) and not for acute disease. Our 
physician reviewer found that therefore, it was not expected that the patient would have required hospital care 
that would have likely crossed 2 midnights.  
 
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 inpatient admission and stay have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient admission and stay.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix (J0485). 
 
You asked the Plan to pre-approve Nulojix. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that parenteral belatacept (J0485) is not proven to be 
safe when administered in the home setting and therefore will be denied as not medically necessary when 
provided in that setting. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the Nulojix is being requested for 
in home administration. Based on this information, we decided that Medicare rules for coverage of Nulojix 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Nulojix (J0485).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000-26-59 provided on June 9, 2023. 
 
You asked the Plan to pay for procedure code 76000-26-59. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed is not supported in the records. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 76000-26-59. Our reviewer 
says that the records do not support the code billed. Our physician reviewer found the medical records provided 
do not validate that procedure code 76000-26-59 was performed as a distinct, separate procedure unrelated to 
code 22214-59 which was also performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 76000-26-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76000-26-59 provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-implanted continuous glucose monitor (CGM) or 
receiver (E2103) and supply allowance for a non-implanted CGM (A4239). 
 
You asked the Plan to pre-approve a non-implanted CGM or receiver and supply allowance. The Plan denied 
your request. The Plan says this request does not meet the requirements for approval. 
 
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 you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a non-implanted CGM or receiver and supply allowance have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-implanted continuous glucose monitor (CGM) or receiver (E2103) and 
supply allowance for a non-implanted CGM (A4239).