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 per CMS guidelines, the patient meets the IRF 
criteria and is reasonably expected to participate in and benefit from 15 hours of therapy a week and requires 
daily physician oversight to actively manage medical conditions and comorbidities to optimize recovery and 
avoid re-hospitalization during intensive rehabilitation. The Plan denied your request. The Plan says the 
services that the enrollee needs can be provided safely in other settings, for example, a skilled nursing facility, 
home with home health services or home with outpatient therapy.  
 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 enrollee's nursing, medical and rehabilitation needs 
do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee 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 enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress. 
 
You asked the Plan to pre-approve the item. You say that you have heart surgery and skin grafts on your chest 
and need a comfortable mattress. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have no evidence of pressure sores, or history of any recent skin grafts or flaps. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered pressure reducing air mattress.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiotherapy (IGRT) (77387x10, G6002x10). 
 
You asked the Plan to pre-approve IGRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of IGRT in the setting of palliative treatment of 
a thoracic bone lesion have not been demonstrated in the peer-reviewed literature. 
 
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 IGRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was seen in consultation by a radiation oncologist and a course of (palliative) 
radiotherapy to a total dose of thirty (30) gray (Gy) in ten (10) fractions was recommended, using intensity-
modulated radiation therapy (IMRT) technique and daily cone beam computed tomography (CBCT). Daily 
IGRT using either daily kilovolt (KV) or daily CBCT is indicated to ensure the safety and accuracy of radiation 
delivery and should be approved. Using daily IGRT is particularly important when treating the spine/vertebral 
body (to ensure treating the correct level) and especially when using the IMRT technique. Daily IGRT is 
medically necessary for radiation treatment in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
image-guided radiotherapy (IGRT) (77387x10, G6002x10).  
 
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 requested services are medically necessary. The 
Plan denied your request. The Plan says 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 enrollee is medically stable with no acuity or complexity despite comorbidities 
which are stable and does not need a physical medicine and rehabilitation physician's supervision 3 times a 
week in an IRF. There are no acute rehabilitation skilled nursing needs identified or documented. Our reviewer 
found that the enrollee does not need specialized intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. 
The documentation does not support necessity for admission to an IRF due to lack of acute medical 
illness/complexity or nursing needs. Our physician reviewer also found that the enrollee's rehabilitation needs 
can be provided in an alternate and low intensity setting such as in a skilled nursing facility or in-home with 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arthroflex dermal allograft. 
 
You asked the Plan to pre-approve Arthroflex. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Arthroflex. Our reviewer says that the 
requested Arthroflex is not considered medically reasonable and necessary in this case. Our physician reviewer 
found Arthroflex dermal allograft is experimental as more research is needed. Therefore, the reviewer found 
that the requested Arthroflex 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 Arthroflex have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Arthroflex dermal allograft.
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 CardioMEMS device. You say that this device is approved by the Food 
and Drug Administration (FDA). You also say that this will enhance the care of the enrollee and reduce the risk 
of future hospitalizations. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the CardioMEMs device has not been demonstrated in the peer-reviewed literature. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer found that the requested CardioMEMS system 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
January 19, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 87481 or CPT 87653 does 
not have a modifier to bypass the edit with CPT 87801. Additionally, CPT 87798 was reported with appended 
modifier -XU for unusual non-overlapping service to bypass the edit with CPT 87801. The laboratory report 
does not contain documentation to support the rationale of using this modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87653, and 87798 rendered on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on November 10, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you were not aware the provider became out-
of-network. 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 the podiatry services 
provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT) (77370, 77373, 77470). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee has metastatic urothelial carcinoma to the 
left hip area involving the left acetabular region. The enrollee is a candidate for SBRT. The Plan denied your 
request. The Plan says that there is no good evidence the SBRT treatment is safe or effective for the enrollee's 
cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT is generally indicated for enrollees with oligometastatic disease or 
for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a state of 
metastatic disease with metastases few in number and extent. Most trials are specific to spine metastases 
(which this enrollee is being offered). For this enrollee, there is only one site of metastasis which is to be 
treated with radiotherapy SBRT. The concept of oligometastases is not related to a specific primary not to a 
specific site or sites of metastases (and therefore would include an abdominal wall metastasis). Maximum 
disease burden is defined by technically safe treatment with curative intent (applies as the radiation oncologist 
is able to treat this enrollee and adhere to recommended dosimetric constraints). Oligometastases that develop 
after original diagnosis are considered metachronous oligometastases (which would be what this enrollee is 
considered to have). In summary, despite mixed data, based on American Society for Radiation Oncology 
(ASTRO)/European Society for Radiotherapy and Oncology (ESTRO) consensus guidelines, SBRT would be 
considered to be furnished in accordance with accepted standards of medical practice. As such, the decision is 
favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiotherapy (SBRT) (77370, 77373, 77470).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 13, 2023, to 
April 11, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that a NOA must be submitted for the first period of care, using 
the first date of the period as the admission date. Subsequent claims must report this date as the admission 
date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from March 13, 2023, to April 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 23, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct information. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with a correct type of 
bill. 
 
We reviewed the file and the Medicare rules. We find that the type of bill billed with this claim was 130. This 
means this claim is not payable as billed. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided on March 23, 2023.
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 cannot be adequately 
cared for in their current condition at a SNF or any other level of care. You would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 appears to be improving with current treatment 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. There are no services at the LTACH that the patient requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility 
is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 sufficient strength and function in upper extremities to manage the standard power 
drives. The enrollee is able to dress themselves, prepare food in the microwave, and transfer themselves to the 
toilet. 
 
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 additional power wheelchair accessories (E2311, E2313, E2377).