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 will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says criteria for admission to the acute inpatient rehabilitation setting have 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 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: 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 appeal of the denial 
for acute inpatient rehabilitation services for the enrollee. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), a stance flexion feature (L5845), a fluid stance extension (L5848) and 
an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature 
(L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee meets coverage criteria based on 
Medicare guidelines. Additionally, the proposed prosthesis is the least level of technology available to meet his 
functional needs. The Plan denied your request. The Plan says the request for a K3 microprocessor knee does 
not meet Medicare criteria as reasonable and necessary. Medicare Guidance says that a prosthesis that meets, 
but does not exceed, the enrollee's need can be provided. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested prosthetics exceed the enrollee's needs and does not meet LCA A52496 
and Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any 
items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. The documentation does not support the need for a 
microprocessor knee. The documentation indicates the enrollee is currently a K2 ambulator with a walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828), a stance flexion feature (L5845), a fluid stance extension (L5848) and an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856).
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 feel the enrollee's health will quickly deteriorate 
without aggressive therapy and careful monitoring of their comorbidities. The Plan denied your request. The 
Plan says the enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that the service requested is medically necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
requested MRI does not meet the criteria to be medically reasonable and necessary. Our physician reviewer 
found reports of the prior MRI scans, electromyography (EMG) and nerve conduction studies are not sufficient 
to establish medical necessity of the requested MRI scans without a physical exam, plan of treatment or even 
history. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current setting.  
 
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 requested services are medically necessary, reasonable and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. However, these services are able to be obtained at the acute care hospital where the enrollee is currently 
receiving 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections (64483, 
64484). 
 
You asked the Plan to pre-approve repeat transforaminal epidural steroid injections. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the following certain requirements 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 repeat transforaminal epidural steroid 
injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found there 
is no role for a series of epidural steroid injections. Each injection must be evaluated for duration and degree of 
effectiveness before proceeding with another injection. Also, the LCD requires 50% pain relief for 3 months. 
Therefore, the request for an epidural steroid injection 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 repeat transforaminal epidural steroid injections have not been met. Therefore, 
we decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections (64483, 
64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. 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. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope or any other apparent indication for an ILR. In summary, there is insufficient documentation to 
support the medical necessity for insertion of an ILR in this 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 the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from March 16, 2023, to March 31, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that this copay amount is too high. You 
should not have to pay so much. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 per 
day copayment, days 1-20; and a $75 copayment per day, for days 21-100 for each Medicare-covered SNF stay 
for skilled nursing facility (SNF) care.  
 You have been asked to pay a $525 total copayment for a SNF stay ($75 copayment x 7 days = $525). This 
item/service falls within the skilled nursing facility (SNF) care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a skilled nursing facility (SNF) stay provided from March 16, 2023, to March 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive  laboratory visits provided from July 14, 2023, to July 24, 
2023. 
 
You asked the Plan to waive  labs. You say that these are too many copayments. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay your 
maximum out-of-pocket (MOOP) is $3,625 for outpatient diagnostic tests and therapeutic services and 
supplies. You have been asked to pay $1,192.47 towards this MOOP amount. 
 You have been asked to pay your maximum out-of-pocket (MOOP) is $3,625 for labs. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive  laboratory visits provided from July 14, 2023, to July 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided on July 24, 2023, to 
August 9, 2023. 
 
You asked the Plan to pay for behavioral health services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says it 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 pay for behavioral health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records provided that it was not expected this enrollee would improve in a 
reasonable period of time beyond the dates in question as the enrollee was not showing any dangerousness to 
self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of 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 the enrollee did not 
have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health services have not been met. Therefore, we decided that the 
Plan does not have to pay for behavioral health services provided on July 24, 2023, to August 9, 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 an IRF admission is medically necessary. 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 enrollee's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy, and it is unclear if they would tolerate. There is not a reasonable expectation that this 
enrollee will be able to benefit from the intensive rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right genicular 
nerves (64624). 
 
You asked the Plan to pre-approve RFA of the right genicular nerves. 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 RFA of the right genicular nerves. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental/investigational therapy. It is the subject of 
ongoing clinical trials. Therefore, 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 RFA of the right genicular nerves have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right genicular nerves (64624).
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 IRF admission is better suited to help your 
condition faster. The Plan denied your request. The Plan says you do not meet the criteria for the IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 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 as 
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.