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

 
We decided that the Plan does not have to pre-approve Axolotl and Palingen wound treatment. 
 
You asked the Plan to pre-approve wound therapy. You say that this authorization should be approved. 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 wound therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is undergoing routine debridement with dressing changes and instructions to 
offload the left foot. It is unclear why the enrollee would require advanced skin substitutes when the ulceration 
is healing. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Axolotl and Palingen wound treatment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface 
application (0394T) and therapeutic radiology simulation aided field setting (77280, 77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you are requesting reconsideration 
for the denial and have provided medical records for review. The Plan denied your request. The Plan says the 
records do not show that the enrollee has undergone clinic staging, consideration for resection of the remaining 
lesion, or consideration for alternate treatment options. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested electronic brachytherapy is not medically necessary for the enrollee 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high dose rate electronic brachytherapy, skin surface application (0394T) and 
therapeutic radiology simulation aided field setting (77280, 77290).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
You asked the Plan to pre-approve a Barostim Neo 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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary 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 a Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shock reducing pylon for a lower limb prosthesis 
(L5988). 
 
You asked the Plan to pre-approve a shock reducing pylon for a lower limb prosthesis. You say that this feature 
is medically necessary. The Plan denied your request. The Plan says this item exceeds the enrollee's needs. 
 
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 foot. 
 
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 shock reducing pylon for a lower limb 
prosthesis. Our reviewer says that the requested feature is not medically necessary. Our physician reviewer 
found the documentation does not reveal that the patient's functional activities or activity level require the 
shock reducing pylon feature. 
 
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 shock reducing pylon for a lower limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a shock reducing pylon for a lower limb 
prosthesis (L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve the microprocessor knee. You say that this knee is medically necessary. The 
Plan denied your request. The Plan says the requested prosthesis component exceeds the enrollee's needs. 
 
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 microprocessor knee. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found the records do not support that the 
enrollee's activities require a heavier microprocessor knee over a mechanical 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 the microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary for open 
wounds. 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 that in this 
case, the documentation doesnt support that you require additional skilled nursing services to provide 
treatment that is medically necessary. You do not require additional skilled nursing services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services 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 18 home health skilled nursing visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on April 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 the services. Our reviewer says that the use of code 99285 is 
not supported by the records provided. Our reviewer found that the provided documentation does not sufficiently support a high level of medical decision making. A moderate level of decision making was 
displayed in the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99285) provided on April 2, 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition, they do not meet all of the requirements.  
 
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. The enrollee's 
medical status does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies including physical or occupational therapy in 
an intensive rehabilitation program in an IRF. While the enrollee may  benefit from additional therapy the 
documentation does not support that the enrollee requires this therapy on an IRF level.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve episodic home health visits. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request does not meet the requirements for approval. 
 
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 that in this 
case, the documentation doesnt support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services 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 episodic home health visits.
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 need this care. The Plan denied your request. 
The Plan says your condition does not meet the criteria for an 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. You require treatment by 
multiple therapies, including physical therapy and occupational therapy, but this can be provided in a lower 
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 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 for 
the enrollee's complex care needs. The Plan denied your request. The Plan says the enrollee can receive the 
care needed in another 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 enrollee is receiving appropriate care in the current acute care setting as provided 
by the Health Plan. Documentation does not support that LTACH services are medically appropriate at this 
time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for posterior tibial nerve stimulator placement performed on July 11, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of a failure or intolerance to standard anticholinergic drug 
therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that posterior tibial nerve stimulation is covered for 
treatment of urinary urgency, urinary frequency, and urge incontinence, when there is documentation of failure 
of standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug 
therapy. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records document a failure or intolerance of standard anticholinergic drug therapy (trospium). 
The records show that the enrollee has urinary urgency, urinary frequency, and urge incontinence. As such, 
posterior tibial nerve stimulator treatment on July 11, 2023 was 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 the services have been met. Therefore, we decided that the Plan has to pay for 
posterior tibial nerve stimulator placement performed on July 11, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an LTACH 
admission for their ongoing acute care needs and close monitoring of their other complex wound and medical 
conditions with an aggressive regimen of physical rehabilitation as tolerated. The Plan denied your request. The 
Plan says admission to an LTACH 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 that the enrollee developed abdominal pain and was found to pneumoperitoneum and 
abscess. The enrollee underwent exploratory laparotomy involving right colon resection and drainage of abscess. A wound vac and Jackson-Pratt drains were left in place. The enrollee's course was complicated by 
aspiration pneumonia, non-ST-elevation myocardial infarction, metabolic encephalopathy, and wound 
dehiscence. The most recent chest radiography shows worsening of interstitial opacities. Per the most recent 
note, the enrollee still demonstrated signs of metabolic encephalopathy. There was also mention that the 
enrollee had been experiencing increased pain in the right upper quadrant. The enrollee is not stable enough for 
transfer to LTACH at this time. The enrollee can continue to receive the care in current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits (97110, 97162) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee must use network providers to get her medical care and 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits (97110, 97162) to be provided by an out-of-network (OON) provider.