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 the enrollee meets IRF criteria and requires intensive 
inpatient rehabilitation with daily physician management, continuous rehabilitation nursing and intensive 
therapies to optimize mobility and strengthening while ensuring the restoration of functional status for a safe 
and sustainable discharge. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for admission to an IRF.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are submitting medical records to support the 
request for reconsideration of the denial of a SNF admission. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, 
provided records do not document a significant decline in the enrollee's functional status compared to their 
recent baseline to necessitate daily inpatient skilled therapy services. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Records support 
that services in the home with home health care or in a long-term care facility on a part-time basis are 
appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that you should be reimbursed because it is 
impossible to have a tooth filled unless it is examined. The Plan denied your request. The Plan says the denial 
of payment for this service is correct, because only preventative dental examinations are covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on March 28, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services provided OON. You say that the enrollee 
was in a nursing home setting at the time the services were rendered. You say that the enrollee couldn't choose 
an in-network internal medicine provider, as they do not provide services in the patient's place of residence. 
You say that the OON provider had no prior knowledge of which patients they will be required to see. You say 
that most patients require urgent care, and it is not possible to request authorization before services are rendered. The Plan denied your request. The Plan says services from non-participating providers are not 
covered under open access unless pre-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 chronic care management services provided on 
March 28, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided on April 4, 2023, to April 7, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that you have 
submitted medical records and request reprocessing of this claim. The Plan denied your request. The Plan says 
code 99233 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for subsequent hospital inpatient or observation care. Our 
reviewer says that the service provided does not meet criteria for payment on this claim. Our reviewer found 
that on April 4, 2023, and April 5, 2023, code 99233 was billed. Documentation supports a medically 
appropriate history/examination, high level of decision making is not supported in the medical record. For high 
level of medical decision making, in this case, documentation supports medical decision making of moderate 
complexity, as new break through seizure is documented. Therefore, a more specific code would be reported. 
Our reviewer also found that on April 6, 2023, and April 7, 2023, code 99233 was billed. Documentation 
supports a medically appropriate history/examination, high level of decision making is not supported in the 
medical record. For high level of medical decision making, in this case, documentation supports medical 
decision making of low complexity, and a more specific code would be reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital inpatient or observation care have not been met. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided on April 4, 2023, to April 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to regain prior level of 
independence. The Plan denied your request. The Plan says the enrollees medical condition does not require 
IRF services, and care can be provided in another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. . While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
Therefore, the requested inpatient rehabilitation facility admission is not approved.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria. 
 You asked the Plan to pre-approve Nyvepria. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the Plan's preferred 
drug, Udenyca. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Nyvepria. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Udencya. The reviewer found that there is no 
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Nyvepria, 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 Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria.
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 requested IRF services are necessary because you 
cannot walk independently and are having balance and dizziness issues. The Plan denied your request. The 
Plan says you do not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services described by code 96521 provided on July 25, 2023.

You asked the Plan to pay for OIVIT services. You say that the OIVIT services should be paid as billed because they are supported in the documentation. The Plan denied your request. The Plan says The OIVIT services are denied because they are not supported in the documentation.

The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services described by code 96521 provided on July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's doctors and family are in 
agreement that LTACH would be the next best and safe discharge. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not already 
available at the acute care hospital where they are currently receiving care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to the 
LTACH would not be clinically advantageous at this time and completion of treatment at the current facility is 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Liver MultiScan procedure (0648T). 
 
You asked the Plan to pre-approve a Liver MultiScan procedure. You say that a Liver MultiScan is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a Liver MultiScan is 
experimental/investigational. 
 
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 Liver MultiScan procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available records do not support that the requested Liver MultiScan as 
requested will alter the enrollee's current 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 a Liver MultiScan procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Liver MultiScan procedure (0648T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 97014. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 97014 billed for date of service March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related accessories and features. You say 
that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says 
rules for coverage for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Group 3 power wheelchair and related accessories and features is being requested for use 
in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power 
wheelchair with multiple power options (K0861) and related accessories and features.