Persius/hicric huggingface dataset:
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 due to the enrollee's complex medical 
needs, the best course of treatment is an admission to an LTACH. You would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not 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. 
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet the requirements for admission to a SNF.  
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee qualifies for SNF coverage as of July 25, 2023. The enrollee does not 
have documented skilled nursing needs. The enrollee does have documented skilled therapy needs.  As of July 
25, 2023, the enrollee was advanced to full weight bearing. A period of skilled therapy is medically necessary 
and reasonable to see if the enrollee can return to their prior level of function. Daily skilled services are 
required to establish a maintenance program and to prevent deterioration of the enrollees condition. The 
enrollees care needs cannot be provided at 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) Provided 
on September 27, 2022, through October 19, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item should be 
covered. The Plan denied your request. The Plan says this is not a covered item. 
 The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) Provided on September 27, 2022, 
through October 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infliximab. 
 
You asked the Plan to pre-approve Infliximab. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Infliximab is covered when 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 Infliximab. Our reviewer says that 
Infliximab is not medically necessary. Our physician reviewer found the medical literature lists fistulizing 
Crohn's disease and moderate to severe Crohn's disease in patients with an inadequate response to conventional 
therapy as FDA-approved uses for Infliximab (Remicade). There is no documentation to support either 
for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infliximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infliximab.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99306 billed for date of service December 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that the provider does not have the capacity to bill directly for the services 
rendered. 
 
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 find that the billing provider is eligible to provide services under Medicare. The rendering provider is an 
internal medicine provider. The rendering provider is not among those who are not eligible to enroll in 
Medicare. Based on this information, we decided that Medicare rules for coverage of the billed services have 
been met. Therefore, we decided that the Plan has to pay for procedure code 99306 billed for date of service 
December 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need orthotics to function normally again. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.
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 admission to the IRF is necessary because you are 
unable to care of yourself and you want to be able to perform you daily activities. The Plan denied your 
request. The Plan says you do 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 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the documentation does not support that the enrollee has tried and failed abobotulinumtoxinA or 
incobotulinumtoxinA. The documentation does not support that abobotulinumtoxinA or incobotulinumtoxinA 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) 
supplies (A4595), purchased on October 23, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that the items should be covered. The Plan denied 
your request. The Plan says a TENS unit is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that separate allowance will be made for replacement 
supplies when they are reasonable and necessary and are used with a covered TENS.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS supplies have not been met. Specifically, a TENS unit is not covered for the enrollee's 
diagnosis which means the supply allowance is also not covered. Therefore, we decided that the Plan does not 
have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) supplies (A4595), purchased on 
October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record significantly complies with the various documentation requirements for IRF 
admission. The enrollees condition is in fact complex, and there is every reason to expect that the enrollee will 
participate in and benefit from services to include physical therapy, occupational therapy, physician 
management of pain and bladder issues, and case manager coordination of any additional services that might be 
needed to ensure a sustainable return home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0428-NR and A0425 NR) 
provided on January 3, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration for the 
services. The Plan denied your request. The Plan says R53.1 (Weakness) and R54 (Age-related physical 
debility), should not be reported together which is based on the Excludes1 Notes instructions in the ICD-10-
CM Official Guidelines for Coding and Reporting. 
 
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 ambulance services. Our physician 
reviewer found that the diagnoses codes R53.1 and R54 cannot be reported together. Diagnosis code R53.1, has 
an Excludes1 note that states that the following diagnoses codes cannot be reported with R53.1: R54 (age 
related weakness), M62.81 (muscle weakness (generalized), M62.84 sarcopenia and R54 senile asthenia.  
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services (A0428-NR and A0425 NR) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom sleep apnea appliance fabrication and placement 
(D9947). 
 
You asked the Plan to pay for the custom sleep apnea appliance fabrication and placement (. You say that the 
item should be covered. The Plan denied your request. The Plan says this is a dental service and you do not 
have any supplemental dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the custom sleep apnea appliance 
fabrication and placement (D9947).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes purchased on January 2, 2023. 
 
You asked the Plan to pay for the diabetic shoes. You say that the item should be covered. The Plan denied 
your request. The Plan says you purchased this item through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic shoes purchased on January 
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 you need rehabilitation services in order to make a 
full recovery to return home. The Plan denied your request. The Plan says you do not meet the 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 you do not require treatment by multiple therapies. 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: 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 further physical and occupational therapy services 
are needed in a SNF. The Plan denied your request. The Plan says you do not meet the Medicare Criteria for 
SNF services.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit.  
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor kit. The Plan denied your request. The Plan 
says conditions for coverage are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre 2 sensor kit. Our 
reviewer says that the FreeStyle Libre 2 is not medically necessary. Our physician reviewer found coverage 
criteria for CGM include insulin use or low blood glucose sugar. Neither seems to be  present here and the 
enrollee is on a medication that should not cause low blood sugar. Coverage criteria for CGM are not met. 
 
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 FreeStyle Libre 2 sensor kit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long-term acute care hospital (LTACH) services provided 
from August 1, 2020, to August 31, 2020. 
 
You asked the Plan to pay for the LTACH services. You say that the request was filed timely but did not reach 
the correct contractor. The Plan denied your request. The Plan says the claim was not filed within the required 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the LTACH services was not filed until March 21, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for long-term acute care hospital (LTACH) services provided from 
August 1, 2020, to August 31, 2020.