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. The Plan denied your request. The Plan says the enrollee's records 
show to have complex rehabilitation needs. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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 all lower extremity prostheses, multi-axial rotation unit 
(L5986) all lower extremity prosthesis, shank foot system with vertical loading pylon (L5987) addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system 
(L5781). 
 
You asked the Plan to pre-approve the K3 Taleo Harmony foot. You say that please see enclosed 
documentation from the enrollee's medical provider showing why the advanced foot with ankle features is 
needed. The Plan denied your request. The Plan says the request for prosthesis with K3 foot exceeds the 
enrollee's need and does not meet the Medicare criteria of reasonable and necessary. There are not enough 
studies to show vacuum socket is safe and effective for the enrollee's condition. 
 
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 the K3 Taleo Harmony foot. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a K3 Taleo Harmony foot (L5986, L5987, L5781) exceed the enrollee's 
medical needs. The treating medical provider documentation does not support that the enrollee is a K3 
ambulator given the need for mobilizing in a wheelchair and walker. The enrollee's functional needs can be met 
with a lower-level foot. The use of vacuum pumps for residual limb volume management and moisture 
evacuation systems among lower extremity amputees is unproven and not medically necessary due to 
insufficient evidence of safety and/or efficacy. The requested L5781 is not medically necessary per 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 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 the K3 Taleo Harmony foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve all lower extremity prostheses, multi-axial rotation unit (L5986) all lower 
extremity prosthesis, shank foot system with vertical loading pylon (L5987) addition to lower limb prosthesis, 
vacuum pump, residual limb volume management and moisture evacuation system (L5781).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedure listed under Current 
Procedural Terminology (CPT) code(s): 20930, 22853, 63052, 22633, 22840, 63053 are not listed on the 
Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is 
currently approved as an ambulatory procedure and there is no documentation provided to support the 
expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The planned procedure listed under code(s): 20930, 22853, 63052, 22633, 
22840, 63053, are not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. There is no documentation provided to support 
the expectation the enrollee will require a greater than two (2) midnight stay. The review has determined that 
the record did not show that the admitting physician reasonably expects that the enrollee's necessary hospital 
care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
records show the enrollee does not show symptoms severe enough to need medical care at this level. 
 
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 at the present acute care hospital. 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. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration stating the 
enrollee's clinical condition meets full IRF criteria, and a lower level of care cannot provide the total 
interdisciplinary team approach needed. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's 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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740), pontics (D6245) and core 
buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to properly chew and digest 
the food you are trying to eat. You say you are requesting reconsideration in an effort to promote good dental 
health. The Plan denied your request. The Plan says when you are missing teeth on both sides of your upper or 
lower jaw, your plan will only pay for a partial denture. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental services have been met. 
We did not receive the dental records from your provider to determine if the services met the criteria for 
coverage. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740), pontics 
(D6245) and core buildup (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurophysiology monitoring (95941) 
short-latency somatosensory evoked potential study (95938) neuromuscular junction testing (repetitive 
stimulation, paired stimuli) each nerve, any one method (95937) needle electromyography, other than 
paraspinal (95870) special electroencephalogram (EEG) tests (95955) provided July 21, 2022. 
 
You asked the Plan to pay for the diagnostic testing services. You say that the services were rendered at the 
request of the surgeon for safety during surgery. The Plan denied your request. The Plan says the services are 
not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the diagnostic testing services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided and review of the current medical literature, 
there is no documentation that the intraoperative neurophysiology monitoring for date of service July 21, 2022, 
at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The 
provided records in this case document the monitoring was performed at the request of the surgeon with no 
other specific details provided with regard to the enrollees condition or details of the surgery which required 
the monitoring services.  
 
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 diagnostic testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the intraoperative neurophysiology monitoring (95941) short-latency 
somatosensory evoked potential study (95938) neuromuscular junction testing (repetitive stimulation, paired 
stimuli) each nerve, any one method (95937) needle electromyography, other than paraspinal (95870) special 
electroencephalogram (EEG) tests (95955) provided July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) provided by a 
denturist. 
 
You asked the Plan to pre-approve the dental service. You say that you are requesting reconsideration stating 
a denturist is in fact a dental health care provider that is licensed by the dental board. You say this is having a 
negative impact on your health, and you need to decide whether you go with another company that will provide 
care at a denturist. The Plan denied your request. The Plan says there is coverage for complete dentures 
however, there is no coverage for services rendered by a denturist. 
 
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 items or services are not 
among those covered under this benefit when provided by someone other than a dentist. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary partial denture (D5225) provided by a denturist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on December 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says the Intracept 
procedure is considered investigational as a treatment option for back pain. 
 
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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows many disc bulges and the cause of 
back pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral 
bodies with imaging guidance, lumbar or sacral (64628).
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
 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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for inpatient rehabilitation admission. Services needed may be provided safely in a 
lower level of care. 
 
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. 
 
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 pay for the supplies provided on November 14, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The date on 
provided proof of delivery does not match the date of service in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the supplies provided on November 14, 2022.