Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) with a hematologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you are requesting a second opinion because the 
in-network provider did not assist you with the issue you have with fibrosis. The Plan denied your request. The 
Plan says you must use network providers to get your medical care and services. The service can be provided 
by a participating provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99214) with a hematologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captain's chair, 
patient weight capacity up to and including 300 pounds (K0823x13 months). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee is unable to walk even short 
distances due to muscle weakness. He is unable to effectively perform tasks of daily living without assistance, 
he can do with a seated scooter. The Plan denied your request. The Plan says the records do not show that the 
enrollee would be unable to safely use a scooter to perform your mobile activities of daily living (MADLs). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 The file shows that the enrollee does not have a mobility deficit that impairs his participation in MRADLs, or 
his condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds 
(K0823x13 months).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health. 
 
You asked the Plan to pre-approve inpatient behavioral health. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee is not receiving active treatment, or the treatment bring 
provided is not expected to be of clinical benefit. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected this 
enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not 
showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as she did not have dangerousness to self or others and was compliant with her treatment. The health plans 
denial of continued inpatient psychiatric services is appropriate. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis beyond the date in question. I am unable to 
find an individualized treatment plan however the entire record is not present. It did appear that the records 
were supervised and evaluated by a physician. Based upon review the records provided for the admission of 
this enrollee does not meet the criteria for August 16, 2023, forward as this enrollee was not shown to be a 
danger to herself or others, delusions, auditory or visual hallucinations noted. She was cooperative/compliant 
with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient behavioral health.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize his prior level of functioning prior to returning home. The Plan denied your request. 
The Plan says based on Medicare guidelines, 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall.  Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does have chronic 
respiratory failure and does meet requirements for bilevel positive airway pressure (BIPAP) with successful 
treatment per documentation. The enrollee does not have documented failure of BIPAP or BIPAP with average 
volume-assured pressure support (AVAPS). Hence, the home ventilator is not indicated 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer with compressor rental provided for date of 
service February 21, 2023.  
 
You asked the Plan to pay for the nebulizer with compressor rental . You say that the clinical records support 
payment for this device. The Plan denied your request. The Plan says the diagnosis codes billed are not 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM diagnosis codes with an Excludes1 
note indicate other diagnoses with which the code with the note should not be reported.   
We looked at the file and Medicare rules. The claim was billed with diagnosis code J45.998 and R06.2. 
Diagnosis codes in the J45 code set have an Excludes1 note for diagnosis code R06.2. As such, these codes are 
not appropriately reported together. Based on this information, we decided that Medicare rules for coverage of 
the nebulizer with compressor rental have not been met. Therefore, we decided that the Plan does not have to 
pay for the nebulizer with compressor rental provided for date of service February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve diabetic shoes and inserts to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diabetic shoes and inserts to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) fusion (27279). 
 
You asked the Plan to pre-approve an SIJ fusion. You say that the enrollee has had several sacroiliac joint 
injections over the years. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an SIJ fusion is covered when all the criteria listed in 
the Medicare rules section 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 an SIJ fusion. Our reviewer says that 
this procedure not medically necessary. Our physician reviewer found that the LCD requires imaging of the 
pelvis and hip, which are not included in the documents included for review. All other criteria are met. At this 
time, the request is deemed 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 an SIJ fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) fusion (27279).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, spine without contrast. 
 
You asked the Plan to pre-approve CT scan, spine without contrast. You say that you disagree with the denial 
of the requested CT scan. The Plan denied your request. The Plan says the CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan, spine without contrast. Our 
physician reviewer found a CT scan for three weeks of back pain without any red flag symptoms is not 
medically 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 CT scan, spine without contrast have not been met. Therefore, we decided that 
the Plan does not have to pre-approve CT scan, spine without contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the procedure is medically 
necessary. You say the pain and symptoms affects the enrollee's quality of life and activities of daily living. 
The Plan denied your request. The Plan says the bone marrow aspirate 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 bone marrow aspirate. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the bone marrow aspirate procedure 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 that the enrollee has prior functional loss and is chronically functionally impaired. 
The enrollee does not require daily skilled therapy. The enrollee also cannot respond due to her inability to 
comprehend and is near her baseline. 
 
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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to a medical 
appointment. The Plan denied your request. The Plan says the requested transportation exceeds the Plan's 
mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. The requested transportation in this case is 
greater than 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips for 
dialysis treatment. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
60-trip limit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ILR. 
 
You asked the Plan to pre-approve an ILR. You say that you are appealing the denial for an ILR. The Plan 
denied your request. The Plan says implantable loop recorders are not needed for routine assessment of those 
with atrial fibrillation.  
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an  implantable cardiac monitor. In summary, there is insufficient documentation to support the medical necessity 
for insertion of an implantable cardiac monitor in the 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ILR.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 the complexity of your nursing, medical, and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require 
physical therapy and occupational therapy services, but the medical records provided do not clarify why you 
require an intensive inpatient rehabilitation therapy program. The provided medical records do not support that 
the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such 
as in a skilled nursing facility is not appropriate for your care 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request is not medically necessary. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has severe functional loss and a pressure ulcer that requires daily 
skilled nursing 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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.