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 this is medically necessary The Plan denied your 
request. The Plan says this 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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. 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 the enrollee would meet criteria for admission to an acute inpatient 
rehabilitation facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you have multilevel 
degenerative changes in your neck and back. You say that your rheumatoid arthritis is destroying various 
joints. You also say that this causes severe fatigue making it impossible to walk over five minutes. The Plan 
denied your request. The Plan says there is no documentation that you have upper body limitations preventing 
you from operating a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 durable medical equipment (DME). 
Our physician reviewer found the record does not provide evidence that you require a power mobility device to 
complete selfcare in the home.  
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter.
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says the medical information confirms 
that the enrollee does not meet Medicare criteria for IRF admission.  
 
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo system. 
 
You asked the Plan to pre-approve the Barostim Neo procedure. You say that the enrollee has tried all available 
options of conservative therapy. You also say that this device has been approved under a Humanitarian Device 
Exemption. The Plan denied your request. The Plan says 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 the Barostim Neo procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Barostim Neo system is an electronic pulse generator implanted 
underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator 
delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In August 2019, the Food and Drug Administration (FDA) approved the system for use in patients 
with refractory heart failure who remain symptomatic despite treatment with guideline-directed medical 
therapy, are New York Heart Association Class III, have an ejection fraction less than 35%, and are not 
candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal 
daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels.  
 
However, there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Barostim Neo procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of a Barostim Neo system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you do not have the skills to care for the enrollee at 
home. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an 
SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The 
enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable 
and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that radiofrequency is necessary when 2 successful 
branch blocks are performed. The Plan denied your request. The Plan says 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not reveal a detailed physical exam of this patient who also has a history of 
spinal stenosis confirming that the patient's knee pain is purely from osteoarthritis and not being referred from 
the spine. The documentation is not clear that the patient's pain appears to be due to a  classic mononeuritis but 
that  neurodiagnostic studies have failed to provide a structural explanation. There is no evidence of complex regional pain syndrome. The documentation does not reveal that the nerve blockade is being used 
diagnostically and not for long term treatment. This blockade is not being used for occipital neuralgia, 
suprascapular neuralgia, trigeminal neuralgia, preemptive analgesia, post surgical pain control. Additionally, 
the documentation indicates that the the appellant is requesting reconsideration stating genicular branch blocks 
for this patient radiofrequency ablation is necessary when 2 successful branch blocks are performed with 80 to 
100% relief. A review of the literature indicates that there is insufficient evidence to support the use of 
genicular nerve blocks and genicular radiofrequency ablation for the treatment of knee osteoarthritis. 
 
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 pre-approve a left genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve tumor treatment field therapy (E0766). 
 
You asked the Plan to pre-approve the service. You say that the requested services are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested services are not 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 the service. Our physician reviewer 
found the enrollee has met all of the coverage criteria for tumor treatment field therapy (E0766) for the 
treatment of newly diagnosed Glioblastoma Multiforme (GBM) listed in LCD L34823. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve tumor treatment field therapy (E0766).  
 
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 waive the cost-share the administration of the injection (96372) and 
the denosumab injection (J0897) provided October 10, 2022. 
 You asked the Plan to waive the cost-share the services. You say that this claim should have been paid in full 
as previous claims were for the same procedure. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2022 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges and 20% coinsurance for 
Medicare Part B Prescription Drugs. For the administration of these drugs, you will pay the cost-sharing that 
applies to outpatient hospital services (as described under Outpatient Hospital Services in the benefit chart) 
depending on where you received drug administration or infusion services.  
 
Review of the file shows that you received an injection on October 10, 2022. The Medicare-allowed amount is 
less than the set $375 copayment for outpatient services; therefore, you have been asked to pay $61.42 for the 
administration of the injection. The allowed amount for the injection itself was $987.48. You have been asked 
to pay a $197.50 coinsurance for surgery services ($987.48 x 20% =$$197.50). Your total responsibility is 
$258.92 ($197.50 + $61.42 = $258.92). This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share the 
administration of the injection (96372) and the denosumab injection (J0897) provided October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 10, 
2022, to October 12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 acute inpatient hospital care. 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 based on the stability of the enrollee, it was not expected that they would require 
hospital services that would likely have crossed 2 midnights or led to an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on October 10, 2022, to October 12, 
2022.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet the guidelines 
for LTACH services. 
 
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 appears to be improving with current treatment but is still somewhat 
unstable for transfer 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 transfer. The patient 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 the patient is not yet stable for transfer and as it would not be clinically advantageous. 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (procedure code 97110, 97112, 
97116, and 97140) rendered from August 7, 2023, to August 30, 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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 97110: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 
 
CPT 97112: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 
 
CPT 97116: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 
 
CPT 97140: 
 
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or 
more regions, each 15 minutes 
 
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 there is no documentation of the 
time spent providing any of these services. 
 
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 physical therapy services (procedure code 97110, 97112, 97116, and 97140) rendered from 
August 7, 2023, to August 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary to gain full recovery. 
The Plan denied your request. The Plan says skilled nursing facility services are being discontinued because 
continuation of SNF is not medically necessary and does not meet Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has achieved the full recovery available to her non-weight-bearing 
status. The enrollee does not require continued daily skilled therapy to restore or maintain function. There are 
no daily skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.