Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
established defining criteria for a medically appropriate LTACH admission. The Plan denied your request. The 
Plan says that 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does meet criteria for LTACH due to their complex and non-healing wounds. As a 
result, they will need a more specialized wound care team than offered at a skilled nursing facility. Treatment 
of the enrollee's wounds will also require a multidisciplinary team involving a nephrologist to closely monitor 
mineral imbalances that further impair the healing of their wounds. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided April 
12, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. The definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry 
analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, 
GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-
MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of 
service. 
 
Codes G0483 remains not supported. The medical records submitted did not include which drug classes are 
ordered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (80307 and 
G0483) provided April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the requested items are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items 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 pre-approve the durable 
medical equipment (DME). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and 
function in upper extremities to manage standard power drives. 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 durable 
medical equipment (DME) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor. You say that the enrollee would benefit from 
the FreeStyle Libre 2 reader.  The Plan denied your request. The Plan says in the record provided, it is noted 
that the enrollee does not take insulin and has not had problems with low blood sugars.  
 
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. Our 
reviewer says that the FreeStyle Libre 2 sensor is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee is being 
treated with insulin or has problematic hypoglycemia as defined by Medicare rules. The elements of the 
coverage criteria are not satisfied. 
 
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 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says Procrit is not being prescribed for a medically accepted indication. 
 
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 drug. Our physician reviewer found 
this case does not meet one of the criteria/indications as laid out in the LCD for erythropoietin. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Procrit (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet radiofrequency ablation (RFA) of the left-sided 
L4-5 and L5-S1 regions.  
 
You asked the Plan to pre-approve the left-sided RFA services. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says there is no record of prior 
radiofrequency ablation to the left regions. 
 
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 left-sided RFA services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has chronic low back pain. The enrollee is taking Flexeril, Baclofen 
and Gabapentin. There is no documentation of the enrollee having 2 sets of diagnostic blocks.  
 
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 left-sided RFA services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet radiofrequency ablation (RFA) of the left-sided L4-5 and L5-S1 
regions.
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 weak and need physical therapy. The Plan 
denied your request. The Plan says you do not meet the guidelines for services in an IRF 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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to a 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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and related accessories and features. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the request is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested power wheelchair 
and related supplies are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple power 
options (K0861) and related accessories and features.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits (97164). 
 
You asked the Plan to pre-approve the therapy services. You say that the requested services are a necessity for 
your care. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore, 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 the therapy services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional 
physical therapy visits (97164).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are appealing the 
denial with supporting documentation. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
does not have high risk for skin breakdown, does not use a catheter intermittently, does not have spasticity or 
require an alternative means of managing power drive control. As the power wheelchair base is not medically 
necessary the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you have cervical spinal stenosis 
and lumbar spinal stenosis and are fully bed bound and cannot reposition yourself without assistance. You 
believe the fully electric hospital bed will assist you and your caregivers. The Plan denied your request. The 
Plan says the requested hospital bed is not covered; the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
 
 
 
 
 
 
 
 
 
 While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion, multi-level. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is having significant lower extremity 
weakness and sexual dysfunction in the setting of a grade 2 spondylolisthesis and severe spinal canal stenosis. 
You also say that the enrollee is not a candidate for further physical therapy given the progressive findings. The 
Plan denied your request. The Plan says the recent imaging does not show that the enrollee has an unstable 
spine at each planned surgical level. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding recent, reasonable and comprehensive less invasive treatments being tried and failed. In addition, documentation regarding the June 8, 2023, x-rays of the 
lumbar spine is not evident corroborating instability at all of the requested surgical levels. The x-rays showed 
grade 2 anterolisthesis of L5 on S1 with subluxation seen on extension suggesting instability consistent with 
pars defects. However, there is no indication of significant pathology at the L3-4 levels. This is further 
corroborated by the magnetic resonance imaging dated June 20, 2023, showing mild encroachment upon the 
bilateral neural foramina without direct intraforaminal neural impingement at the L3-4 level. Inevitable 
temporary intraoperative instability has also not been clearly delineated as probable. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested multilevel lumbar fusion at levels L3-5 is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar fusion, multi-level.
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 services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that 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 admission are met in this 
case. Our physician reviewer found the L3-5 laminectomy may be safely performed with a 48-hour 
observational stay. 
 
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.