Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric inpatient hospitalization. 
 
You asked the Plan to pre-approve psychiatric inpatient hospitalization. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 psychiatric inpatient hospitalization. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee presented to the hospital for detoxification. Based on 
the documentation, it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as the enrollee was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The 
documentation does not support that it is medically necessary and reasonable to have psychiatric care provided 
at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee 
did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 
Therefore, the enrollee does not meet criteria for the requested acute inpatient mental health treatment beyond 
the date in question and be treated in a lesser restrictive setting as the enrollee was not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or 
aggression being cooperative and compliant while not showing any acute threats to 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 psychiatric inpatient hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve psychiatric inpatient hospitalization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence showing that the requested device would improve 
outcomes. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to be under professional direction to 
practice safe mobility skills to avoid fatal falls. You also say further reports from care providers have been 
added, and you would like them reviewed. The Plan denied your request. The Plan says  records show your 
condition does not meet the requirements for coverage of SNF services.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
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 rehab because you were 
independent before your hospitalization, and you want to return to being independent. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
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 enrollee is deconditioned with chronic illness and does not require intensive 
rehabilitation services. They significantly improved over a weekend with low level to no acute hospital 
inpatient services.  
 
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 would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical 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 this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal simplicity interspinous-interlaminar fusion 
device. 
 
You asked the Plan to pre-approve spinal simplicity interspinous-interlaminar fusion device. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the minuteman may be covered if certain criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve spinal simplicity interspinous-
interlaminar fusion device. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the spinal simplicity 
minuteman interspinous-interlaminar fusion device at issue in this case meets all Medicare criteria for 
medically reasonable and necessary and safe and effective for the patient. Information from the device 
manufacturer states:  
"The Minuteman is a minimally invasive, interspinous-interlaminar fusion device intended for the stabilization 
and fusion of the thoracic, lumbar, and sacral spine. The Minuteman is designed for attachment to the posterior 
non-cervical spine at the spinous processes through its bilateral fixation plates, and it is intended for use with 
bone graft material placed within the device. It provides immobilization, stabilization, and fusion of the spinal 
segments. The core threaded post allows for optimal placement and a wide range of sizes allows for enhanced 
anatomical fit. The Minuteman is delivered sterile and individually packed."  
Provided records in this case do not document that the device will be used with bone graft material as 
recommended by the manufacturer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal simplicity interspinous-interlaminar fusion device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve spinal simplicity interspinous-interlaminar 
fusion device.
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 of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical 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 this enrollee will be able to fully 
participate in, and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the services. You say that the documentation supports a lymphedema 
diagnosis, overall severity, and the presence of unique characteristics necessitate treatment with the prescribed 
device. The Plan denied your request. The Plan says the requirements 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a request was made for a segmental compression pump. However, the provided records did not show 
the patient with lymphedema of the chest/trunk/abdomen area, nor were there characteristics that would 
indicate a segmented pump over a standard pump. Although there was documentation of failure of a standard 
pump trial in-office, the notes describe only trace edema in the lower legs/feet without evidence of skin 
breakdown or wounds to justify a pump unit of any kind.  
 
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 pneumatic compression device (E0652, E0656, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 28, 
2023. 
 You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 71046. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve injections. 
 
You asked the Plan to pre-approve the nerve blocks. You say that due to the failure of conservative treatments 
to address pain and restore function this procedure is necessary. The Plan denied your request. The Plan says 
the request 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 nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular nerve injections.
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be provided in an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 enrollee has not tried and failed the 
Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Injectafer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 22853 and 22551. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 20930.  
 
You asked the Plan to pay for surgical services (20930, 22853 and 22551) provided on April 25, 2023. You say 
that these services were necessary and are supported in the medical record. The Plan says that these services 
were billed with two diagnosis codes which cannot be reported together. In addition, code 20930 is considered 
bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 22853 and 22551.  
 
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 rules also say that providers must comply with ICD-10-CM coding guidelines. One such 
guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with 
which they cannot be reported. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we are unable to confirm that the diagnosis codes reported (M46.42 
and M50.123) are subject to an Excludes1 note in relation to one another. This means that these codes are not 
excluded from being reported together. Based on this information, we decided that the Medicare billing rules 
for procedure codes 22853 and 22551 are met, and the Plan has not provided a reason for denial of these codes 
which can be substantiated. Therefore, we decided that the Plan has to pay for the services described by 
procedure code(s) 22853 and 22551.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
20930. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 20930 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 20930. 
 
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.