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 lives by themselves and is prepared to 
get extra help at discharge. The Plan denied your request. The Plan says an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney transplant. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is contraindicated. 
 
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 procedure is not medically reasonable or necessary. Our physician reviewer found that while human 
immunodeficiency virus (HIV) is not a contraindication for transplant, the patient must be on therapy and with 
undetectable viral load levels. The enrollee is also immunosuppressed, with white blood cell abnormalities. The 
enrollee also has ongoing use of illicit drugs. The enrollee would not be eligible for transplantation. The 
enrollee would need therapy for HIV with objective success and drug rehabilitation prior to becoming a candidate. 
 
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 kidney transplant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 23, 
2023. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the records do not 
support the code.  
 
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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. 
 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 billed code. Our reviewer found that the 
enrollee was treated in the hospital with a partial intestinal obstruction related to colon cancer with metastases 
to liver treated with surgery. A surgical follow-up note described the enrollee as tolerating liquids, 
asymptomatic, passing flatus, and with stable vitals, and nontender abdomen. The documentation included brief 
but appropriate history and examination, however, it does not support a moderate level of medical decision-
making to justify the code, 99232. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99232 billed for date of service March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor kit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a 
diagnosis of diabetes treated with insulin or a history of problematic hypoglycemia with documentation of level 
two hypoglycemic events persisting despite multiple attempts to adjust medications and/or modify the diabetes 
treatment plan. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM) sensor kit.
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 needs IRF services as he requires 
multiple therapeutic disciplines due to decline in functional ability. The Plan denied your request. The Plan 
says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees 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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on June 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and a garment. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested PCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half 
leg (E0673) provided on June 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee may be at risk of losing his maximum 
ability to function and is medically needing more acute care. The Plan denied your request. The Plan says the 
records do not show the enrollee will be able to take part in three hours of therapy a day at least five days a 
week or 15 
hours per week: The Plan says services may 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. The medical 
records support 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. It 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test provided on June 1, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that the Cxbladder test was medically necessary.  
The Plan denied your request. The Plan says the Cxbladder test was 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 Cxbladder test. Our reviewer says that 
the requested Cxbladder test is not considered medically reasonable and necessary. Our physician reviewer 
found the CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. 
Current American Urological Association (AUA) guidelines do not recommend CxBladder for bladder cancer 
screening or monitoring. Urinary biomarker tests such as CxBladder give significant false-negative results in 
patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage 
and low-grade tumors.   
 
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 Cxbladder test have not been met. Therefore, we decided that the Plan does 
not have to pay for the Cxbladder test provided on June 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening digital breast tomosynthesis and screening 
mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when 
performed provided on July 10, 2023. 
 
You asked the Plan to pay for screening digital breast tomosynthesis and screening mammography, bilateral (2-
view study of each breast), including computer-aided detection (CAD) when performed. You say that the 
screening digital breast tomosynthesis and screening mammography, bilateral was medically necessary. The 
Plan denied your request. The Plan says the screening digital breast tomosynthesis and screening 
mammography, bilateral was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a mammogram is covered when the criteria listed in 
the Medicare rules section of this decision 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 pay for screening digital breast tomosynthesis and 
screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed. Our reviewer says that the requested screening digital breast tomosynthesis and screening 
mammography is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the report describes gynecomastia but there is no dictated indication for a mammographic study on a 
male patient. The typical recommendations for follow-up include those for female patients. The medical 
necessity of the mammographic studies done on this male patient cannot be determined from the submitted 
records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of screening digital breast tomosynthesis and screening mammography, bilateral 
(2-view study of each breast), including computer-aided detection (CAD) when performed have not been met. 
Therefore, we decided that the Plan does not have to pay for screening digital breast tomosynthesis and 
screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of multiple stage 2 or worse pressure ulcers or a 
myocutaneous flap. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has reduced mobility and is noted to have a pressure wound of the coccyx. However, 
there is limited information regarding the staging and measurements of the pressure wound and what type of 
wound care and pressure relief is required. Without this information, the requested powered pressure reducing 
air mattress cannot be considered 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered pressure reducing air mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 5, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the billed testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an authorization was required and not on file. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the lab testing provided on June 5, 2023, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Integra and Apligraf. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider has requested more than one skin substitute product at the same time for the 
same sound. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no reason why the enrollee should use two different skin substitutes for the same wound. 
 
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 Integra and Apligraf.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76870 provided on May 30, 2023. 
 
You asked the Plan to pay for procedure code 76870. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that codes with a status indicator of Q1 are not 
separately payable.  
We looked at the file and Medicare rules. In this case, the service in dispute was billed along with code 99285. 
Code 99285 has a status indicator of V. Billed code 76870 has a status indicator of Q1. This means that this 
code is not separately payable. Therefore, we decided that the Plan does not have to pay for procedure code 
76870 provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve integrated drive wheel motor and gear box combination, 
replacement only (E2370) foam filled tire (E2386) and repair or nonroutine service for durable medical 
equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes 
(K0739). 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that please review for appeal. There are no 
duplicate repairs, no warranty info applicable, and the chair is less than 5 years old. The Plan denied your 
request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds the estimated 
expense for replacement of the wheelchair. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record shows the cost of the wheelchair is $9,049.61. The 
combined repairs cost totals $10,188.51. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-
approve integrated drive wheel motor and gear box combination, replacement only (E2370) foam filled tire 
(E2386) and repair or nonroutine service for durable medical equipment other than oxygen equipment requiring 
the skill of a technician, labor component, per 15 minutes (K0739).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical records submitted do not establish that the admission into the 
IRF is reasonable and 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 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. Your medical problems 
are stable and there are 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.