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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive medical care and 
therapy that can't be provided in a lower rehabilitation setting. The Plan denied your request. The Plan says 
based on Medicare guidelines, the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility or in-home with 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 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 pay for procedure codes 99204, G0283, and L0637 billed for date of 
service January 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically appropriate and 
necessary. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; Medical decision making of moderate complexity. We find that code 99204 is not 
supported. The enrollee was seen and treated for low back pain. The records do not show that medical decision 
making of moderate complexity was provided. 
 
The definition of code G0283 is electrical stimulation (unattended), to one or more areas for indication(s) other 
than wound care, as part of a therapy plan of care. The records do not include a plan of care for the services 
provided as required.  
 
The definition of code L0637 is lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and 
posterior frame/panels. The records show that durable medical equipment was provided. However, the 
documentation does not specify what equipment was provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99204, G0283, and L0637 billed for date of service January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
enrollee does not need this item. Our physician reviewer found the medical records do not include 
bronchiectasis confirmed on chest imaging. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
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 the care due to dialysis. The Plan denied 
your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to go home, you have non-weight 
bearing orders for three months, and need rehabilitation services. The Plan denied your request. The Plan says 
your records show that it is not reasonable to expect that you need, nor would fully benefit from, the intensity 
of services of an IRF. 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of an ankle fracture after a fall. Your medical problems are stable, and you have no complex 
nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the documentation does not support that enrollee required care is 
too complex to be provided at 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 5, 2023, to 
February 3, 2023. 
 You asked the Plan to pay for the home health services. You say that the required NOA has been submitted. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2023. The NOA was not received by the Plan until April 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 5, 2023, to February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the item is necessary. The Plan denied your request. 
The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 1, 2022, to 
March 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that some claims have paid with the 
same NOA, so you do not understand this denial. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 1, 2022, to 
March 2, 2022.
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 your records do not 
show you meet the requirements for admission. The Plan says that the 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 your 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 a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not require a home 
ventilator. The records do not show failure of bilevel positive airway pressure (BIPAP) or BIPAP with average 
volume-assured pressure support (AVAPS). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve amnioband or guardian skin substitute (Q4151). 
 
You asked the Plan to pre-approve amnioband or guardian skin substitute. You say that this is medically 
necessary. The Plan denied your request. The Plan says not medically necessary. Records do not show that the 
enrollee has a wound that is failing to respond to standard wound care. 
 
The Plan follows Medicare rules. Medicare rules say that application of a skin substitute graft for lower 
extremity chronic wounds will be covered when specific criteria are met. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve amnioband or guardian skin substitute. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
documentation demonstrates that this enrollee has undergone amputation of the second and third digits left 
side. They are unfortunately suffering with a necrotic fifth digit left side. The medical documentation does not 
advise on wound measurements, nor does the medical documentation advise on conservative care/wound care 
including dressing changes, offloading, wound vacuum-assisted closure (VAC), activity modification etc. 
Medicare guidelines advise that application of a skin substitute graft for lower extremity chronic wounds will 
be covered if the patient is noted to be neuropathic and diabetic, have undergone conservative wound care 
measures greater than four weeks, and the patient must not have osteomyelitis or a nidus of infection. The 
medical documentation does not support that this patient meets the above-mentioned guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of amnioband or guardian skin substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve amnioband or guardian skin substitute (Q4151).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service April 3, 2023, to May 2, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the number 
of days exceed the acceptable maximum. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The file shows that the start of care date is April 3, 2023. The claim dates do not exceed the start date plus 29 
days. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request.  Therefore, we decided that the Plan has to pay for the home health care 
billed for dates of service April 3, 2023, to May 2, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure (LAAC) 
device (Watchman device). 
 
You asked the Plan to pre-approve placement of a LAAC device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 pre-approve placement of a LAAC device. 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 a history of atrial fibrillation and flutter. There is an 
elevated risk of thromboembolic stroke due to atrial fibrillation and high CHADS2VASC score. The enrollee 
had a GI bleeding in 2017 when on dual platelet agents, not anticoagulant. As such, guidelines would not 
support implantation of a LAAC in this setting. In summary, outpatient LAAC placement would not be 
considered reasonable or medically necessary in the clinical management of 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 placement of a LAAC device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a left atrial appendage closure (LAAC) device (Watchman 
device).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral knee orthoses (L1852) and bilateral lower 
extremity suspension sleeves (L2397). 
 
You asked the Plan to pay for the bilateral knee orthoses and bilateral lower extremity suspension sleeves. You 
say that the items are medically necessary. The Plan denied your request. The Plan says there is no 
documentation of recent knee injury, knee surgery, or knee instability. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s), or who is ambulatory and has knee instability. 
 
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 bilateral knee orthoses and bilateral 
lower extremity suspension sleeves. Our reviewer says that the enrollee does not need these items. Our 
physician reviewer found there is no documentation of recent knee injury, knee surgery, or knee instability. 
 
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 bilateral knee orthoses and bilateral lower extremity suspension sleeves 
have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral knee orthoses 
(L1852) and bilateral lower extremity suspension sleeves (L2397).