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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided July 15, 2022, to July 18, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that this admission 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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided July 15, 2022, to July 18, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for home health services provided from February 24, 2022, to March 24, 
2022. 
 
You asked the Plan to pay for home health services. You say that the home health services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that the NOA was submitted untimely. 
The case record does not include a copy of the NOA to verify untimely submission. It is the Plan's 
responsibility to support its denial with evidence. In this case, the Plan's denial has not been supported, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for home health services provided from 
February 24, 2022, to March 24, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics.

You asked the Plan to pre-approve the upgraded electronics. You say that the requested power wheelchair is necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show a medical need to control the power options through a joystick.

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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not support that it is medically necessary to control the approved power options through the joystick (drive interface). The reviewer found that the documentation supports that your upper extremity strength and functional ability as evidenced by being independent for feeding with the power wheelchair should be sufficient to control any power options through their own switches. Therefore, the reviewer found that the request for upgraded electronics 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection device for a power wheelchair. 
 
You asked the Plan to pre-approve controller and electronic upgrades. You say that this will maximize the 
enrollee's independence and quality of life. The Plan denied your request. The Plan says the enrollee's upper 
limb strength and function are adequate to control the power options using their own switches. 
 
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 controller and electronic upgrades. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has adequate upper body strength to manage standard power 
drive controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of controller and electronic upgrades have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller, harness, and electronic connection device 
for a power wheelchair.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on October 19, 2022, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for an x-ray. You say that this is supported in the record. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 an x-ray provided on October 19, 2022, by an out-
of-network (OON) provider.
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 an LTACH admission is the best option 
for a safe discharge due to enrollee's current needs. 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care 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 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: 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 is impulsive, distractible, and a high fall 
risk. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 harness for upgrade to expandable controller (E2311), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
and expandable controller (E2377). 
 
You asked the Plan to pre-approve a harness, electronic connection, and expandable controller. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria 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 harness, electronic connection, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate strength to 
manage standard power drives. The items are not medically necessary to meet the enrollee's needs. 
 
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 harness, electronic connection, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a harness for upgrade to expandable 
controller (E2311), electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 5 through 
November 7, 2022.  
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records provided support 
the need for the inpatient services in dispute.  The Plan denied your request. The Plan says the enrollee's 
emergency medical condition was stabilized as of November 4, 2022.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for coverage have not been met.  Our physician reviewer found as of November 4, 2022, 
the enrollee was stable for repatriation to a network facility because her altered level of consciousness and 
respiratory distress improved/resolved. She did not exhibit any further neurological or respiratory decline. All 
inpatient care provided on November 5 through November 7, 2022, was not needed on an emergent basis. The 
review has determined that the treating physician did not document (in the physician notes, on a form, or in an 
order) that the enrollee was not stable for transfer on any dates of service. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on November 5 through November 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on March 18, 2022, billed with 
codes 77003, J3490, and A4550. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says code 77003 is an add on code and was billed 
without a valid primary procedure. Codes J3490 and A4550 are included in the global package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
testing services provided is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Codes J3490 and A4550 are 
included in the global package and are not separately payable. Therefore, we decided that the Plan does not 
have to pay for testing services provided on March 18, 2022, billed with codes 77003, J3490, and A4550.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Irreversible Electroporation (IRE) with NanoKnife. 
 
You asked the Plan to pre-approve IRE. You say that this is medically necessary to treat the enrollee's cancer. 
The Plan denied your request. The Plan says that this service hasn't been proven to be a helpful treatment for 
the enrollee's health problem. 
 
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 Irreversible Electroporation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that IRE is not medically reasonable and necessary in this case. IRE 
including use of the NanoKnife for tissue ablation is considered experimental and investigational for treatment 
of prostate cancer due to insufficient evidence in the peer-reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Irreversible Electroporation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Irreversible Electroporation (IRE) with NanoKnife.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a Minuteman G5 interspinous device 
at L4-L5. 
 
You asked the Plan to pre-approve an interspinous device. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the requested procedure 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 an interspinous device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Minuteman interspinous device is experimental and more research is 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 an interspinous device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a Minuteman G5 interspinous device at L4-L5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of lymphedema of the chest or trunk. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no evidence of truncal or chest edema. There is only bilateral lower extremity lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (PCD) (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve upgraded electronics. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the upgraded electronics are 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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has right hemiparesis and is able to feed themself independently. Per 
SSA 1862 (a)1(A) as the enrollee has adequate upper body strength to manage standard power drive controls, 
this is not medically necessary to meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) harness (E2313) and electronic connection 
(E2311).