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 the enrollee extremely needs inpatient rehabilitation. 
The Plan denied your request. The Plan says the records do not show the enrollee can participate in three hours 
of therapy a day at least five days a week or 15 hours per week as you are dependent for ambulation and 
transfers. The Plan says that the services needed may be provided safely in a lower level of care.  
 
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.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport services and ground mileage 
provided on March 24, 2023. 
 
You asked the Plan to pay for the ambulance transport services and ground mileage. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says ambulance services used for the 
transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is 
considered part of the inpatient admission, and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation services while the enrollee is 
inpatient are not separately payable. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was in an inpatient hospital 
status for this date of service. This means the ambulance services provided are considered bundled and are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance 
transport services and ground mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance transport services and ground mileage provided on March 24, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for  procedure code 71045 billed for date of service March 29, 2023. 
 
You asked the Plan to pay for  the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says that the service is reimbursed once to a single provider. 
 
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. 
 
We looked at the file and the rules. The claim shows that 1 unit of code 71045 was billed. The Plan has not 
provided any other claim to show this service was billed more than once. The MUE for CPT code 71045 is 4. 
The MAI value for this code is 3. You billed 1 unit of this code. The case file does not show that the maximum 
number of units have been exceeded. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for  procedure code 71045 billed for date of service March 29, 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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not the standard of care for this patient's condition or in widespread use for this 
patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient.  There is insufficient evidence in the literature 
that this device will increase participation in bimanual activities.  
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that insertion 
of a subcutaneous cardiac rhythm monitor is medically necessary. The Plan denied your request. The Plan says 
a subcutaneous cardiac rhythm monitor is considered reasonable and necessary when you have episodes of 
syncope (loss of consciousness) that are thought to be cardiac-related but don't happen often enough to be 
detected by a Holter monitor (portable device to record heart rhythms). The clinical information provided to us 
shows no history of or recent episodes of syncope. 
 
The Plan follows Medicare rules. Medicare rules say that insertion of a subcutaneous cardiac rhythm monitor is 
covered when the criteria listed in the Medicare rules section of this decision 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 insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the requested insertion of a subcutaneous cardiac rhythm monitor is not 
considered medically reasonable and necessary. Our physician reviewer found that while the enrollee has a 
history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR 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 insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor.
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 feel that you are safer in an IRF Facility. The 
Plan denied your request. The Plan says you 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a translaminar epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a translaminar 
epidural steroid injection 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 injection. Our reviewer says that a 
translaminar epidural steroid injection is not medically necessary. Our physician reviewer found that the LCD 
criteria for repeating the block is 50 % improvement in pain for 3 months, which was not achieved. Therefore, 
the request 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a translaminar epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets the 
requirements for an inpatient LTACH stay. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no 
required medical services identified that are available at the LTACH that are not available at the current health 
care setting being offered by the Plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral brachioplasty (15836). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee has lost a significant amount 
of weight. You say that the enrollee now has hanging skin which affects their activities of daily living. The 
Plan denied your request. The Plan says the requested surgery is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable. 
 
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 surgical service. Our reviewer says 
that the requested bilateral brachioplasty is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has excessive redundant skin following weight 
loss. The record provided does not establish that the requested service is for the prompt repair of accidental injury, to improve the functioning of a malformed body member or for the diagnosis or treatment of an illness 
or injury. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the reviewer found that the request for the bilateral 
brachioplasty 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the bilateral brachioplasty (15836).
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 admission is medically necessary for you. The Plan 
denied your request. The Plan says you have multiple medical issues, these issues are stable and do not 
complicate care in the current setting and you require physical and occupational therapy. The Plan says that the 
services needed may be provided safely in a lower level of care.  
 
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 needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 18, 2023, and billed with codes 87481, 87500, 87640, 87652, and 87798. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on May 18, 2023, and billed with codes 87481, 87500, 87640, 87652, and 87798.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for levocarnitine, and a vitamin b-12 injection provided on April 
27, 2023. 
 
You asked the Plan to pay for levocarnitine, and a vitamin b-12 injection. You say that the claim should be 
reprocessed.  The Plan denied your request. The Plan says a vitamin b-12 injection and levocarnitine is not 
medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for levocarnitine and a vitamin b-12 injection. 
Our reviewer says that a vitamin b-12 injection and levocarnitine is not medically necessary. Our physician 
reviewer found that the enrollee has a diagnosis of peripheral neuropathy. However, the requested drugs are not 
FDA-approved. The requested drugs levocarnitine and a vitamin b-12 injection are also not supported by one of 
the major drug compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of levocarnitine and a vitamin b-12 injection have not been met. Therefore, we 
decided that the Plan does not have to pay for levocarnitine, and a vitamin b-12 injection provided on April 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services received on April 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like these services reimbursed at 
the Medicare allowed rate. The Plan denied your request. The Plan says the services received are not covered 
by this type of provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the laboratory services received on April 
17, 2023.
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 enrollee requires inpatient rehabilitation to 
reduce the risk of returning to an acute care hospital. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the services needed may be provided 
safely in a lower level of care.  
 
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.  
 
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.