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 admission is medically necessary and everything the 
the enrollee needs. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 
for medical necessity because the enrollee's medical condition requires further evaluation and treatment in the 
current acute care hospital.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Ossur Rheo Knee and Ossur Proflex foot. 
 
You asked the Plan to pre-approve the Ossur Rheo Knee and Ossur Proflex foot. You say that the item is 
medically necessary. The Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Ossur Rheo Knee and Ossur Proflex 
foot. Our reviewer says that the item is medically necessary. Our physician reviewer found the medical record 
go above and beyond in satisfying Medicare policy by demonstrating this enrollee has K3 functional level 
potential and has specific needs for the requested components. 
 
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 Ossur Rheo Knee and Ossur Proflex foot have been met. Therefore, we 
decided that the Plan has to pre-approve the Ossur Rheo Knee and Ossur Proflex foot.  
 
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 a heavy-duty walker. 
 
You asked the Plan to pre-approve a heavy-duty walker. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a heavy-duty walker is only covered for certain 
indications. 
 
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 heavy duty walker. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a medical history of atrial fibrillation and congestive heart failure. 
The clinical documentation indicates that the enrollee has normal strength, and the enrollee's level of mobility 
and function is not specified. The enrollee is noted to have difficulty with mobility and performing daily 
activities. The enrollee may require a standard walker, but there is a lack of clinical documentation or 
information that indicates that she cannot use a standard walker or has a severe neurological disorder causing 
the restricted use of one hand, which is required for a heavy-duty walker. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
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 heavy-duty walker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty walker.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve a genicular artery embolization. You say that this procedure would provide 
long-lasting pain relief that will improve the enrollee's quality of life. The Plan denied your request. The Plan 
says documentation does not show that the enrollee has intractable bleeding or that this request is for treatment 
of cancer with hepatic artery embolization. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical 
literature do not document that use of genicular artery embolization has been shown in controlled studies in a CMS-approved journal to result in long term health benefits for the enrollee's osteoarthritis of the knee. 
 
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 genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular artery embolization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) physical therapy (PT) home health visits 
(G0151). 
 You asked the Plan to pre-approve home health services. You say that requesting reconsideration stating to 
review the medical records for medical necessity. The Plan denied your request. The Plan says the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
was referred for home health physical therapy after a fall at home. She is noted to be able to ambulate in her 
home without an assistive device. She has been educated in terms of a home exercise program. The enrollee 
may require supervision in terms of safety given her dementia, but this does not require the services of a skilled 
physical therapist. She is noted to have a walker available for fall prevention. Therefore, the additional 3 visits 
of home health physical therapy are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three (3) physical therapy (PT) home health visits (G0151).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 the enrollee. 
The Plan denied your request. The Plan says the enrollee does not require complex rehabilitation, medical or 
nursing needs for 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's medical records overall significantly complies with the various documentation 
requirements for IRF admission. The enrollees condition is in fact complex and fragile, and there is every 
reason to expect that he will participate in and benefit from services to include at minimum physical and 
occupational therapy, physician oversight of polypharmacy, and case manager coordination of any additional 
services that might be needed to make a sustainable return home as well as avoid further preventable re-
admissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you lost your denture while 
you were in the hospital and need a new one. The Plan denied your request. The Plan says your benefit for the 
complete maxillary denture has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested  service was exhausted on date of service July 3, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation. 
 
You asked the Plan to pre-approve inpatient substance abuse rehabilitation. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet the level of care criteria for an 
acute inpatient/detoxification treatment but could have been treated in a lesser restrictive setting. 
 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 substance abuse rehabilitation. 
Our reviewer says that this enrollee does not meet the criteria for treatment in an acute inpatient/detoxification 
setting. Our physician reviewer found the enrollee was not showing any withdrawal symptoms, medical issues 
and was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions. The 
enrollee was not showing any behaviors or aggression being cooperative and compliant while not showing any 
acute threats to safety. Services could have been provided in a lesser restrictive 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 inpatient substance abuse rehabilitation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 24, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's need for ongoing medical 
management and intensive therapy, they are not safe to return directly home at their current level of function. 
The Plan denied your request. The Plan says admission to an IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollees nursing, medical, and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has had a complicated 
hospital course and continues to require closer monitoring of their conditions by a rehabilitation physician. The 
enrollee does require rehabilitation nursing, and their medical and rehabilitation needs do require the intensive 
interdisciplinary approach provided in an IRF. The enrollee does require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at 
least 3 hours a day and 5 days a week, or 15 hours over seven consecutive days. The enrollee has had a decline 
from their baseline level of function and would benefit from the intensity of therapies provided in an IRF. the 
enrollee is able to participate in therapies and requires speech, occupational and physical therapies. 
 
Therefore, the acute inpatient rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable oxygen concentrator. Our 
reviewer says the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found you have multiple co-morbidities that can contribute to hypoxemia and the HAST 
study confirmed that oxygen therapy is required. This is best practice and standard 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 a portable oxygen concentrator have been met. Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator (E1392).  
 
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 a Koya Dayspring Active Compression Garment 
System (K1033, K1024). 
 
You asked the Plan to pre-approve a Koya Dayspring Active Compression Garment System. 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 Koya Dayspring Active Compression 
Garment System. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the proposed device is not the standard of care and 
has not been shown to as effective as the standard of care. There is one small, randomized trial.  
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 Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression 
Garment System (K1033, K1024).
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 it is 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 documentation indicates that the enrollee has been working with therapy and is 
are able to stand up with a walker and light touch assist, as of October 10, 2023. The review has determined 
that 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. 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.  
 
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.