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 prefer to admit to acute rehabilitation because 
you were independent before your hospitalization and want to return to being independent. The Plan denied 
your request. The Plan says based on the available information, admission to an IRF is not reasonable and 
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 your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our reviewer also found that you require treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in 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: 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 ready for discharge and for rehabilitation 
therapy to begin as hospital therapy is not enough. The Plan denied your request. The Plan says based on the 
available information, admission to an IRF is not reasonable and 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 your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our reviewer also found that you require treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in 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 sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that this procedure will be performed as an 
adjunctive therapy to the covered invasive vein treatment on the same date of service. You also say that the 
enrollee's reflux in the larger veins will be treated with Venaseal on the same day. The Plan denied your 
request. The Plan says the larger veins have not been treated for reflux. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee has undergone saphenous vein reflux treatment. The reviewer 
found that the Health Plan does not provide for simultaneous saphenous reflux treatment and tributary 
treatment. Therefore, the reviewer found that the requested sclerotherapy is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 3, 2023, to 
March 25, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like to appeal this denial. 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 September 30, 2022. The NOA was not received by the Plan until 
November 3, 2022. 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 provided from March 3, 2023, to March 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on December 6, 2022, to December 
19, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you experienced technical 
difficulties that caused a disruption to your computer systems. You say that the records provided support the 
services in dispute. The Plan denied your request. The Plan says that the services denied at the time 
authorization/pre-certification was requested. 
 
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 only documented evidence that the Plan provided showing their 
determination for the dates of service in dispute was the provider remittance advice. This provider remittance 
advice listed the Plans denial reason as the services having been denied at the time authorization/pre-
certification was requested. The Plan has not provided any documented evidence showing the 
authorization/pre-certification request or why it was denied. We reached out to the Plan for clarification and 
requesting documentation which demonstrates their appeal determination regarding the actual dates of service 
in dispute. We did not receive a response to this request. Without clear, documented evidence regarding the 
appeal determination for dates of service December 6, 2022, to December 19, 2022, we are left to review the 
Plans original claim denial. This claim denial reason is not supported, as it states the reason for non-payment 
is a pre-certification denial for the services in dispute. However, we have no documentation regarding this pre-
certification denial or why the pre-certification request was denied. The Plan has not substantiated their denial 
reason. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on December 6, 
2022, to December 19, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 7, 
2023, to May 6, 2023. 
 You asked the Plan to pay for SNF care. You say that the services should be covered under the Medicare Act.  
The Plan denied your request. The Plan says the enrollee did not meet the criteria for SNF stay and the services 
were not preauthorized. 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for skilled nursing facility (SNF) care provided from April 7, 2023, to May 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2022, to 
October 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code A41.9 is supported. The Plan denied your request. The Plan says there is insufficient evidence 
for the coding of sepsis A41.9 and the more appropriate principal diagnosis code is N39.0, so the Plan changed 
the DRG to 690. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that this DRG does not meet criteria for payment. Our physician reviewer found the enrollee presented to 
emergency department with general illness and a recent fall. The enrollee developed a fever while in the 
emergency department and had evidence of a urinary tract infection. The enrollee was hospitalized for 
antibiotics and supportive care. The enrollee improved and was discharged. There is no evidence that the 
enrollee had sepsis. As such, the billing of diagnosis code A41.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 4, 2022, to October 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat injection(s), diagnostic or therapeutic agent, 
paravertebral facet joint with image guidance, lumbar or sacral (64493, 64494). 
 
You asked the Plan to pre-approve repeat medial branch blocks (MBBs). You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records do not support that the 
enrollee has tried and failed recent physical therapy.  
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary when there must be a consistent positive response 
of at least 80% relief of primary (index) pain after the first diagnostic facet joint procedure. 
 
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 repeat medial branch blocks (MBBs). 
Our reviewer says that the request for repeat MBBs is not medically necessary. Our physician reviewer found 
the provided documentation does not support that the enrollee had 80% pain relief from the previous injections. 
Therefore, the reviewer found that the request for repeat injections 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 repeat medial branch blocks (MBBs) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the repeat injection(s), diagnostic or therapeutic agent, paravertebral 
facet joint with image guidance, lumbar or sacral (64493, 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided this enrollee does not meet the criteria for October 3, 2023, forward as this enrollee was 
not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations noted. 
She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient's history of recent hospital and emergency 
room admissions demonstrates their medical necessity to reside in a higher level of care such as an IRF. The 
Plan denied your request. The Plan says IRF services are not supported based on the records received.  
 
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 patients nursing, medical, and rehabilitation needs 
do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. Our reviewer found that the patient continues to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation does not support that the patient would meet criteria for admission to an acute inpatient 
rehabilitation facility.  There is no indication that the patient 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 their functional status.  Our physician reviewer also found that the patient 
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 genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. 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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested bilateral genicular 
nerve blocks 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power 
option, captain's chair, patient weight capacity up to and including 300 pounds and accessories (K0857, E1005, 
E1012, E1028, E2311, E2313, E2361, E2377). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee's health and 
quality of life will be dramatically increased with the requested device. Without power recline, he will be 
relegated to bed primarily or be in constant pain and continue the high risk of wounds. The Plan denied your 
request. The Plan says the enrollee does not have medical need for single power options included with group 3 
power wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or 
walker for mobility. He cannot functionally propel a manual wheelchair due to upper extremity weakness. The 
enrollee requires a power wheelchair for mobility and accomplishing his daily activities. However, the clinical 
documentation is insufficient why a lower-level power wheelchair would not meet the enrollee's needs versus a 
group 3 power wheelchair. There is inadequate clinical documentation regarding why he requires power tilt and 
cannot adequately perform pressure relief. There is no history of skin breakdown, and the enrollee has 4/5 
motor strength in the upper extremities. A group 3 power wheelchair base is typically indicated in enrollees 
with significant paralysis due to conditions such as a spinal cord injury. Therefore, the group 3 power 
wheelchair with tilt 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power option, captain's 
chair, patient weight capacity up to and including 300 pounds and accessories (K0857, E1005, E1012, E1028, 
E2311, E2313, E2361, E2377).