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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee' condition does not meet all the requirements. The 
Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 21, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 21, 2023.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two of the ten physical therapy visits.  
 
You asked the Plan to pre-approve 10 additional physical therapy visits.. You say that the enrollee has de-
conditioning and impaired balance and continues to display significant unsteadiness. The enrollee's balance and 
mobility will decline if not allowed to continue with therapy. The Plan says that the requested services are not 
reasonable and necessary, and the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
We decided that the Plan has to pre-approve 2 physical therapy visits.  
 
Our doctor found that two of the requested ten visits of therapy are necessary and appropriate with the 
specialized skill, knowledge, and judgment of a qualified therapist to review and ensure competence in a home 
exercise program. The remaining 8 additional therapy sessions with the skills of a professional therapist are not 
medically necessary.  Therefore, we decided that the Plan has to pre-approve two physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve 8 of the 10 physical therapy visits. 
 
 Therefore, we decided that the Plan does not have to pre-approve 8 physical therapy visits. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and supply allowance. 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that the enrollee would benefit 
from the CGM in order to monitor for hypoglycemia. The Plan denied your request. The Plan says that the 
Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supply allowance. Our 
reviewer says that the CGM coverage criteria was met. Our physician reviewer found that although the enrollee 
is not a actually having low blood sugars or using insulin, the enrollee is being prescribed a new medication 
that can cause low blood sugars and the MD is asking the enrollee to use a CGM to warn the enrollee of the 
low blood sugars. This is a reasonable use of the CGM in an older enrollee who is at risk for low blood sugars 
with Glipizide. 
 
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 CGM and supply allowance have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor (CGM) and supply allowance.  
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp. 
 
You asked the Plan to pre-approve a ramp. You say that you request reconsideration of the denial for a ramp 
your home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per the Plan policy, ramps are medically necessary if a patient is 
wheelchair dependent and unable to enter or exit their home with assistance, has decreased ambulation skills 
and is unable to climb stairs and is only able to leave their home via ambulance and stretcher. The enrollee is 
not a wheelchair user and has the ability to climb stairs with assistance. The enrollee's decline in function is due 
to a a leg fracture which will improve once recovery from the injury is complete. Based on this information, we decided that Medicare rules for coverage of a ramp have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair (A9270). 
 
You asked the Plan to pre-approve a chair. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a chair (A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for admission to 
an IRF. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to an IRF 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 the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollees medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollees 
rehabilitation needs can be safely provided in an alternate and low intensity 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 5 liberty ramp unit (wheelchair ramp). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you need a ramp for your home. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a 5 liberty ramp unit (wheelchair ramp).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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's health, recovery and ability to regain 
maximum function will be adversely affected if required to wait for standard time-frame.The Plan says that the 
services needed may be provided safely in a lower level of care. The Plan denied your request. The Plan says 
the enrollee's records do not show to be able to tolerate 3 hours of therapy per day 5 days a week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for IRF admission. 
The enrollee's condition is in fact complex and fragile, and there is every reason to expect that she will 
participate in and benefit from services to include at minimum physical and occupational therapy, physician 
oversight of post-op course and polypharmacy, and case manager coordination of any additional services that 
might be needed to make a sustainable return home as well as avoid  preventable re-admissions to the acute 
hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that HBOT is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the enrollee has a diabetic foot ulcer, 
occlusion of the anterior tibial artery and distal posterior tibial artery, and A1c of 14 from the previous month. 
He has not failed standard wound care treatment, including appropriate glucose control, wound treatment, and 
correction of arterial occlusion. The criteria for coverage are not met and HBOT is not reasonable or medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for  the definitive drug testing of 15-21 classes (G0482) provided on 
December 15, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-21 classes. You say that this testing should be 
covered as billed.  The Plan denied your request. The Plan says that only 9 drug classes were tested. 
 
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 G0482 is the definitive testing of 15-21 drug classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the claim and 
confirmed that 15-21 classes of drugs were tested. Based on this information, we decided that Medicare rules 
for coverage of the definitive drug testing of 15-21 classes have been met. Therefore, we decided that the Plan 
has to pay for  the definitive drug testing of 15-21 classes (G0482) provided on December 15, 2022.  
 
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 the enrollee is not fully ambulatory and is an extreme 
fall risk. You also say the enrollee cannot perform their activities of daily living without assistance, and 
pursuing outpatient therapy would be highly hazardous as the enrollee is not safe in the home setting and will 
not make adequate progress with the minimal therapies available in a skilled nursing facility. The Plan denied 
your request. The Plan says admission to an IRF 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 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. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary. The 
Plan denied your request. The Plan says inpatient rehabilitation 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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation 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 he 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99205, 99245) with a general surgeon to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that the enrollee needs to be seen by proper surgeons 
and needs surgery as soon as possible. The Plan denied your request. The Plan says the enrollee must use 
network providers for health services and care. There are in-network providers available. 
 
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 
office visits (99205, 99245) with a general surgeon 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 you feel the enrollee would perform best in an IRF. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
admission to an IRF 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 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. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.