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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting 
have not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.
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. The Plan denied your request. The Plan says when the 
enrollee is ready to leave the hospital, services can safely be received this care in another setting at a skilled 
nursing facility. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: 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 are requesting an expedited 
reconsideration stating the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95941, 95938, 95955, 95937) 
provided on December 12, 2022. 
 
You asked the Plan to pay for neuromonitoring services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says these services were not billed correctly and 
should be billed to the hospital facility where they were requested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that inpatient services. The rules say that all items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromonitoring services have not been met. Specifically, these services were furnished for a 
procedure provided to an enrollee in an inpatient hospital (Place of Service code 21) setting. This means they 
should be paid to the hospital and billed by the provider through the hospital under arrangements. Therefore, 
we decided that the Plan does not have to pay for neuromonitoring services (95941, 95938, 95955, 95937) 
provided on December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99307) provided on January 11, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this service was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this claim was submitted with two diagnosis 
codes which cannot be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nursing facility care have not been met. Specifically, this claim lists diagnosis codes Z93.3 and 
Z43.3. However, codes within the Z93 code set have an Excludes1 note for codes within the Z43 code set. This 
means these two diagnoses cannot be reported together. Therefore, we decided that the Plan does not have to 
pay for nursing facility care (99307) provided on January 11, 2023.
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 are requesting an expedited appeal for the 
denial of a SNF admission.  The Plan denied your request. The Plan says criteria for admission to the SNF have 
not been met.  
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipilimumab. 
 
You asked the Plan to pre-approve Ipilimumab. 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. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ipilimumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that based on 
the medical records received, there is no evidence to support that the treatment being denied is safe and/or effective for your cancer metastatic cutaneous squamous cell carcinoma of unknown primary after disease 
progression on a prior checkpoint inhibitor (Keytruda). The requested use of Ipilimumab is not FDA-approved 
for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ipilimumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ipilimumab.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper extremity prosthesis (L7499). 
 
You asked the Plan to pre-approve an upper extremity prosthesis. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an upper extremity prosthesis. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the article the plan refers to for the denied use of L7499 is retired. The requested 
device to restore more function based on the residual function of the fingers is reasonable. 
 
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 upper extremity prosthesis have been met. Therefore, we decided that the 
Plan has to pre-approve an upper extremity prosthesis (L7499).  
 
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: 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 the enrollee showed improvement with therapy and 
needs to continue. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee has COPD, atrial fibrillation, mitral valve replacement, congestive heart 
failure not otherwise specified, obstructive sleep apnea not currently being treated, and rheumatoid arthritis. 
The enrollee was hospitalized in late March with influenza and exacerbation of COPD. An arterial blood gas 
(ABG) showed mild compensated Carbon dioxide (CO2) retention. There are no pulmonary function tests in 
the record. There is no ABG done while stable to document chronic CO2 retention. If that is present, the 
enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0481) provided on December 8, 
2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the code used to report the 
services provided is not the most accurate code to describe these services. 
 
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 G0481 is drug test(s), definitive, 8-14 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided show 
that drugs from more than 14 drug classes were tested in this case. Another CPT code would more accurately report the services provided in this case. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
definitive drug testing (G0481) provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that he requested device is not diagnosis-specific, but 
symptom-specific. You say that it can be considered for any patient when retained secretions cause pulmonary 
compromise. You say that the enrollee has tried and failed huff cough and manual percussion. You also say 
that the enrollee is too fragile for percussion and has insufficient expiratory force resulting in chronic coughing 
and dyspnea. The Plan denied your request. The Plan says the records do not show a confirmed diagnosis of 
bronchiectasis.  
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically necessary. Our physician reviewer found the provided records do not 
document the enrollee has cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high 
frequency chest wall oscillation device (HFCWOD) may be covered. The reviewer found that the records do 
not indicate that the enrollee currently uses a mechanical in-exsufflation device. The reviewer also found that 
the records do not show well-documented failure of standard treatments to adequately mobilize retained 
secretions. Therefore, the reviewer found that the requested device is 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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve the accessories. You say that these electronics are necessary for the 
enrollee's power wheelchair. The Plan denied your request. The Plan says it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has adequate strength to manage multiple power drive controls. The requested 
accessories are not medically necessary to meet the enrollee's 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee has chronic obstructive 
pulmonary disorder (COPD) and is a heavy chronic smoker. You say that the enrollee has asthma-COPD 
overlap syndrome and is currently on Trelegy and Nocturnal Oxygen.  The Plan denied your request. The Plan says there is no indication that there have been any new problems or symptoms since the enrollee's previous CT 
scan in October of 2022.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee has documented chronic obstructive 
pulmonary disease (COPD) and is not asymptomatic. The enrollees last computed tomography (CT) scan was 
on October 5, 2022. The enrollee has no change in symptoms to warrant a CT earlier than one year since the 
last. A 5 millimeter (mm) left upper lobe nodule seen on September 7, 2021, was noted to have decreased in 
size on the October 5, 2022, scan. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs would not be 
appropriately met at a skilled nursing facility and requires a higher level of care. The Plan denied your request. 
The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving on current treatments 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 to 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.