Persius/hicric huggingface dataset:
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 requested IRF services are necessary for you to 
receive the necessary physical therapy and help you walk again. The Plan denied your request. The Plan says 
you do not meet all 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 11, 
2023, through March 12, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
 
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with dyspnea for months, and 
had a recent diagnosis of anemia. There was no report or evidence of bleeding. She did not report chest pain. 
Her vital signs were stable with normal blood pressure and oxygen saturation on room air. The examination 
was unremarkable. Her hemoglobin was repeated and found to be 6.9. She was treated with fluids and a 
transfusion without complication. Other workup results were unremarkable. Based on the provided 
documentation, it was not expected that the enrollee would have required hospital care that would have likely 
crossed two midnights to treat her condition at the time of admission.  
 
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 pay for the acute inpatient hospital care provided from March 11, 2023, through March 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wigs. 
 
You asked the Plan to pay for the wigs. You say that the items should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wigs.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition requires 
the level of care provided at an LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require a transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar percutaneous vertebral augmentation (PVA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the imaging reports document multiple 
potential causes of back pain, in addition to the compression fracture, including foraminal stenosis and facet 
arthrosis. The records do not support that the requested PVA is reasonable and 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 lumbar percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88305 provided on February 20, 2023. 
 
You asked the Plan to pay for procedure code 88305. You say that these services were necessary and were 
billed appropriately. The Plan denied your request. The Plan says that the services provided would be better 
reported with another code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the documentation does not show that the Plan has requested 
medical records for this service, nor have they forwarded any medical records to us for this service. Without 
relevant documentation, we cannot verify whether or not this service was reported appropriately. The Plan has 
not substantiated their denial in this case. Therefore, we decided that the Plan has to pay for procedure code 
88305 provided on February 20, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous stenting. 
 
You asked the Plan to pre-approve venous stenting. You say that the enrollee is experiencing lifestyle changing 
pains. The Plan denied your request. The Plan says the record shows that the enrollee does not have an iliac 
vein compression, iliofemoral obstruction, or thrombosis in the superior or inferior vena cava. 
 
The Plan follows Medicare rules. Medicare rules state that endovenous stenting may be covered for certain 
indications. 
 
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 venous stenting. Our reviewer says that 
the enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee has a history of 
leg pain and claudication with concern for severe peripheral arterial disease; however, there is no 
documentation of a pulse examination provided and no physiologic study provided. The angiogram is not 
provided. The documentation of third-hand reporting of the results is insufficient. The enrollee also complains 
of paresthesias and had a history of Parkinson's disease. There is no documentation of whole leg swelling and 
no documentation that the enrollee's edema is significantly symptomatic. The non-invasive imaging is not 
suggestive of significant proximal venous occlusive disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venous stenting have not been met. Therefore, we decided that the Plan does not 
have to pre-approve venous stenting.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0493, G0496, Q5001) provided on 
March 11, 2023, through March 23, 2023. 
 You asked the Plan to pay for home health services. You say that you are requesting reconsideration. 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 March 11, 2023. The NOA was not received by the Plan. 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 home health services (G0493, G0496, Q5001) 
provided on March 11, 2023, through March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation proves medical necessity. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. Diagnosis codes have an Excludes1 note cannot be reported.  The file shows that diagnosis codes E11.9 and E10.65 were billed on the claim at issue. In this case, we have 
confirmed that diagnosis code group E11 has an Excludes1 note in relation to diagnosis code group E10. This 
means that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for the billed service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A4239 billed for date of service March 10, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the enrollee is at high risk of 
developing lymphedema so use of the bioimpedance spectroscopy device is medically necessary. The Plan 
denied your request. The Plan says that this is not considered to be a standard of medical treatment of the 
enrollee's condition. 
 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found bioimpedance is Food & Drug Administration (FDA) approved for lymphedema 
risk assessment in breast cancer with peer-reviewed evidence to support its use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy.  
 
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 walk-in shower (E1399). 
 
You asked the Plan to pre-approve a walk-in shower. 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 walk-in shower (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring Device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says this device is considered experimental. 
 
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 Koya Dayspring Device. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is considered experimental. 
 
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 Koya Dayspring Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1033).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a parathyroid scan (78070). 
 
You asked the Plan to pre-approve a parathyroid scan. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a parathyroid scan. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the diagnosis of primary hyperparathyroidism has not yet been established. The 
enrollee is on a thiazide, which can increase serum calcium levels. Parathyroid hormone (PTH) and/or reflex 
parathyroid hormone-related protein (PTH-RP) levels are not available. It is also unclear if the 92yr old enrollee is a surgical candidate should an adenoma be localized. The review has determined that the the 
items/services at issue in this case are not medically reasonable or 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 a parathyroid scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a parathyroid scan (78070).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection. You say that you would like the denial to be 
reconsidered based on Medicare approval. The Plan denied your request. The Plan says although a single 
power feature is requested for this wheelchair, there is not a medical need to control this power option through 
the joystick. 
 
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 electronic connection. 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 been non-ambulatory since 2020 due to stroke and arthritis. 
Currently the enrollee is able to feed themself independently and bathe with stand by assistance. Our reviewer 
also found that the enrollee has sufficient strength and function in upper extremities to manage standard power 
drives. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says clinical practice guidelines suggest no support for using Sprint PNS for 
chronic pain. 
 
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 Sprint PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental therapy at this time and is the subject of ongoing clinical 
trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS).
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 cannot get out of bed due to your medical 
problems and need to get your strength back before returning home. The Plan denied your request. The Plan 
says you do not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.