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 you are requesting an expedited reconsideration 
stating the enrollee meets all applicable Medicare criteria for admission to an IRF. The Plan denied your 
request. The Plan says the IRF services requested 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 24, 2022, to 
June 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 183. 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 at the DRG originally billed. Our reviewer says 
that the documentation does not support the DRG billed. Our physician reviewer found the enrollee fell at 
home and was treated in the hospital for rib fractures. The enrollee was treated with analgesics, low dose 
oxygen support, and pulmonary toilet with benefit. The enrollee did not require high flow oxygen support, 
BiPAP, or ventilator support or had significant respiratory distress to meet the definition of acute respiratory 
failure. Therefore, the DRG 183 is not sufficiently supported in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 24, 2022, to June 28, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 ventilator. 
 
You asked the Plan to pre-approve a Life2000 ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested ventilator is not medically necessary. 
 
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 Life2000 ventilator. Our reviewer 
says that the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has chronic respiratory failure from idiopathic pulmonary fibrosis. 
Notwithstanding the fact that the noted condition is not one for which coverage is available under the rules, the 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. 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 Life2000 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Life2000 ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis and decompression of the spinal cord. 
 
You asked the Plan to pre-approve spine surgery. You say that the enrollee has severe neck pain extending 
through both upper extremities toward the pinky and ring fingers with numbness, weakness, and parasthesias. 
The Plan denied your request. The Plan says this 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding significant pathology at all of the requested surgical levels is 
not fully evident. There is a previous fusion at C3-7 without any diagnostic imaging findings of hardware 
failures or pathology that would support the requested revision procedure. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis and decompression of the spinal cord.
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 are requesting reconsideration stating the 
enrollee will need aggressive rehabilitation and continued medical oversight in order to reach their goal of 
returning 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 a knee meniscectomy, meniscal repair, and meniscal 
transplant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain 
occurring for more than three months. The magnetic resonance imaging (MRI) on March 15, 2023 
tricompartmental cartilage disease, medial compartment predominant and severe. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested knee meniscectomy, meniscal repair, and meniscal transplant 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee meniscectomy, meniscal repair, and meniscal transplant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A9286). 
 
You asked the Plan to pre-approve incontinence supplies. You say that these supplies are needed due to 
incontinence. The Plan denied your request. The Plan says these supplies are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A9286).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you are appealing this denial. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 20, 2022, to 
March 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided December 1, 2022, to 
December 6, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that by appending the KX modifier, the provider is 
attesting that the services billed are reasonable and necessary services that require the skills of a therapist, are 
justified by appropriate documentation in the medical record, and qualify for an exception using the automatic 
process exception. 
 
We looked at the file and Medicare rules. Review of the file shows that the services were not billed with the 
KX modifier. Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided December 1, 2022, to December 6, 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 IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare 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 that the complexity of the enrollees 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 enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, a heel wedge. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need approval of the heel cradle because 
you have health problems related to the inequality of the longitude of your lower extremities as well lumbar 
pains and diabetes neuropathy. The Plan denied your request. The Plan says this item is not a covered benefit. 
The information received does not show that you need to use it as part of a leg brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, a heel wedge.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing provided on December 13, 2021. 
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this test is not covered because the enrollee has gastroesophageal reflux disease (GERD) and dysphagia. There 
is documentation or history of Barrett's esophagus. The Plan denied your request. The Plan says this testing was 
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 pay for the WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided records do not 
support the high likelihood of Barretts esophagus (e.g., indeed, no biopsies of the esophagus were obtained at 
the time of 2021 esophagogastroduodenoscopy (EGD). Available records do not support that the spirit of 
American Society for Gastrointestinal Endoscopy (ASGE) guidance is met relative to medically necessary use 
of WATS-3D in this case. 
 
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 WATS cytopathology and histopathology diagnostic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the WATS cytopathology and histopathology 
diagnostic testing provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87640, 
87641, 87798 and 87801) provided on November 14, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test was 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 pay for the urine PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found standard of care for a urinary tract infection is urinalysis with urine culture and sensitivity. 
Multiplex PCR is noninferior to urine culture for detection and identification of bacteria. The review has 
determined that the items/services at issue in this case are 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine PCR (polymerase chain reaction) panel (87640, 87641, 87798 and 87801) 
provided on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve the requested services. You say that your blood sugar drops when you are 
sleeping. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that external infusion pumps are only covered under 
certain medical 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 the requested services. Our physician 
reviewer found that you have diabetes with a C-peptide level of 4 which is not less than or equal to 110 percent 
of the lower limit of normal of the laboratory's measurement method. The record indicates that you have 
normal renal function. The elements of the coverage criteria are not satisfied. Therefore, the requested service 
is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an external infusion pump.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a left knee arthroplasty. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 a left knee arthroplasty. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found There is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 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 left knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee arthroplasty (27447).