Persius/hicric huggingface dataset:
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 a skilled nursing facility will not provide 
adequate physician, nursing, and therapy coverage and care for the enrollee's current health disposition. You 
also say that currently the enrollee is not a candidate for an acute rehabilitation facility as they have too many 
medical complications for a lower level of care. The Plan denied your request. The Plan says the records do not 
show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.  
 
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 is receiving appropriate care in the current acute care setting as provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs an IRF as she is weak. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for an 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found while the enrollee's condition is complex and fragile, there is every reason to expect that she will 
participate in and benefit from the IRF level services. The enrollee's medical record overall significantly 
complies with the various documentation requirements for an IRF admission. Therefore, the requested IRF 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's current level of functioning requires minimum assistance for sit to 
supine transfer and sit to stand transfer. The enrollee needs maximum assistance for lower body dressing. The 
review has determined that 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. 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 Dexcom continuous glucose monitor (CGM), supplies 
and accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that the requested items are a 
medical necessity. You also say that the previous glucose methods did not work for you, were painful and not 
effective. The Plan denied your request. The Plan says the CGM, supplies and accessories are not medically 
necessary.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM, supplies and accessories. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found coverage criteria for 
CGM coverage require insulin use or low blood glucose sugar. You are not on medications that typically cause 
low blood glucose sugar and we are not told of low blood glucose sugar. Although the CGM may be helpful for 
you, coverage criteria are not met. 
 
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 CGM, supplies and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM), supplies and 
accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 22, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization (GAE) with ultrasound 
guidance. 
 
You asked the Plan to pre-approve the GAE. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of a 
GAE for your condition. 
 
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 GAE. Our reviewer says that the 
requested genicular artery embolization (GAE) is not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental as it is the subject of ongoing clinical trials. 
Therefore, the reviewer found that the requested GAE 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 the GAE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular artery embolization (GAE) with ultrasound guidance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 27, 
2023, through February 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with acute on chronic hip pain 
following a fall into a chair then to floor. There was no obvious trauma reported. Her vital signs were stable. 
The examination was unremarkable. She was treated with pain medication. Based on the provided 
documentation, it was not expected that the enrollee would have required hospital services that would have 
likely crossed two midnights. Additionally, there was no indication that the enrollee would have been at risk of 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from January 27, 2023, through February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (0242U) provided on June 13, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for OON laboratory services. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says out-of-network services are only covered in certain 
limited circumstances which have not been met in this case. Neither the rendering nor the referring provider are 
in network with the Plan. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (0242U) provided on June 13, 
2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 24530 provided on April 15, 2023. 
 
You asked the Plan to pay for procedure code 24530. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the records do not support the billed service. 
 
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 24530 is definitive fracture care. 
 
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 procedure code 24530. Our reviewer says that the records 
support the code billed. Our reviewer found the records support that definitive fracture care was performed on 
the date of service. The record states that a long arm splint was applied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 24530 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 24530 provided on April 15, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care 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 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. 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 
inpatient rehabilitation facility. The medical records do not support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 16, 2023. 
 
You asked the Plan to pay for the physician service. You say that you were advised that no referral was 
necessary. You also say that this should be reprocessed. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $800 deductible which applies to medical services.  
 
The item or service you asked the Plan to pay for falls within the physician services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies 
to out-of-network medical physician services. This cost sharing is a contractual obligation that had not been met at the time the physician service was received on February 16, 2023. Therefore, we decided that the Plan 
does not have to pay for the office visit provided on February 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial scintigraphy imaging study (78466). 
 
You asked the Plan to pre-approve a myocardial scintigraphy imaging study. You say that the enrollee may 
have amyloidosis and needs to have this done. You also say that the enrollee's electrocardiogram was 
abnormal. The Plan denied your request. The Plan says the requirements for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a myocardial scintigraphy imaging 
study. Our reviewer says that a myocardial scintigraphy imaging study is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided records in this case do not document 
aortic stenosis, unexplained left ventricular hypertrophy, heart failure, the carrier status of a pathogenic ATTR 
(amyloid transthyretin) mutation, or echocardiographic and/or cardiac magnetic resonance imaging findings suggestive of cardiac amyloidosis.  
 
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 myocardial scintigraphy imaging study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a myocardial scintigraphy imaging study (78466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that minimally invasive treatments 
have failed. The Plan denied your request. The Plan says that this is considered experimental and 
investigational. 
 
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 artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the 
studies are noted to be promising, further research is needed to corroborate that geniculate artery embolization 
is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is presented, or 
extenuating circumstances noted, to support the medical necessity of this request as an exception. 
 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 artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
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 an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services requested 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy however, the 
documentation doesnt support that they 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 three visits weekly to 
regain or maintain their 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.