Persius/hicric huggingface dataset:
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a LTACH.  
 
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. The enrollee does not require services at the LTACH that are 
not already available at the current facility.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need to keep the progress going and not move 
backwards you have been improving in therapy to get stronger. The Plan denied your request. The Plan says 
you are receiving the services needed in the current facility.  
 
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 based on the documentation provided, you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You are doing well with your current therapy. You can complete 
the current course of care before being discharged to 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (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 need rehab to regain strength. The Plan denied 
your request. The Plan says the 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 you do not require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. You do not require 
skilled services on a daily basis. You do not require skilled services 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x5), a core buildup (D2950), and 
removal of residual tooth roots (D7250). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to cover these services. 
The Plan denied your request. The Plan says the requested services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2740 x5), a core buildup (D2950), and removal of residual tooth roots (D7250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen concentrator (E1390), portable gaseous oxygen 
system rental (E0431), stationary compressed gaseous oxygen system rental includes contents (E0424). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the medical records provided support 
the necessity of the requested services. The Plan denied your request. The Plan says the criteria has not been 
met as the records do not include a blood gas result.  
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen equipment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found although the enrollee subjectively has dyspnea and an unconfirmed diagnosis of 
pulmonary hypertension, there are no provided confirmatory studies or imaging interventions to support this 
diagnosis. The enrollee requires an arterial blood gas analysis (ABG), echocardiogram, a right heart catheter or 
an ambulatory desaturation study to at least be considered for home O2 and equipment. Hence, the coverage 
rules are not met, and further data and information is required to prescribe oxygen therapy. 
 
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 oxygen equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve oxygen concentrator (E1390), portable gaseous oxygen system rental (E0431), 
stationary compressed gaseous oxygen system rental includes contents (E0424).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on February 1, 2023, to 
February 27, 2023, billed with code J0604. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says this claim line was not billed with the required 
modifier. 
 The Plan must follow Medicare rules. Medicare rules say that in the event that a drug or biological generally 
used in the treatment of ESRD was furnished to an ESRD beneficiary for reasons other than for the treatment 
of ESRD, the provider may report the drug on the claim with modifier AY and receive separate payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. This claim was not reported with the required 
modifier for the service provided. Therefore, we decided that the Plan does not have to pay for Practitioner 
services provided on February 1, 2023, to February 27, 2023, billed with code J0604.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator electrodes. 
 
You asked the Plan to pre-approve implantable neurostimulator electrodes. You say that the enrollee needs this 
dorsal spinal cord stimulator. The enrollee has chronic pain cause by lumbosacral arachnoiditis that has not 
responded to medical management. The Plan denied your request. The Plan says this implanted device 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 implantable neurostimulator electrodes. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation of an adequate trial and failure of physical 
therapy for backpain. More conservative measures are needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable neurostimulator electrodes have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantable neurostimulator electrodes.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need more time to build strength to be able to 
do normal activities. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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 you do not require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. You do not require 
skilled services on a daily basis. You do not require skilled services 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 skilled nursing facility (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 the rehab is needed for the enrollee to maximize 
ability to safely transition home. The Plan denied your request. The Plan says the 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 
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 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: 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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
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 intravenous infusion services (procedure code 96366) 
rendered on December 2, 2022. 
 
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 Current Procedural Terminology (CPT) 96366 remains not supported. 
 
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 96366 is "Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure)." 
 
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 although intravenous infusion 
was provided, the documentation supports Outpatient intravenous insulin therapy (OIVIT), and in this case a 
more appropriate code should be reported. Therefore, procedure code and units billed cannot be verified. 
 
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 intravenous infusion services (procedure code 96366) rendered on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for admission to 
an IRF and will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says under Medicare, the requested IRF admission 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 that based on the documentation provided, the enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy, electrical stimulation, vasopneumatic 
devices, and subcutaneous injection services performed on February 27th, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, because the records do not show an established 
diagnosis with confirmatory testing. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records did not show evidence from blood work that there was a vitamin deficiency present to 
confirm this diagnosis before considering treatment for such. An appropriate diagnosis was not made. 
 
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 pay for physical therapy, electrical stimulation, vasopneumatic devices, and subcutaneous injection 
services performed on February 27th, 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 you need the rehab due to have two artificial legs 
that are not functioning properly. The Plan denied your request. The Plan says the 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 you do not require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. You do not require 
skilled services on a daily basis. You do not require skilled services 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 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 the Optimizer Smart procedure. 
 
You asked the Plan to pre-approve Optimizer Smart. You say that the denial for this procedure is unwarranted. 
The Plan denied your request. The Plan says there is a lack of evidence to support this procedure as a safe and 
effective alternative to standard treatments. 
 
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 Optimizer Smart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure remains the subject of multiple studies examining long-term efficacy 
as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such studies are 
completed, it is premature to presume clinical outcomes and benefits.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Optimizer Smart procedure.