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 services are medically necessary due to the 
enrollee's deconditioned state and they require daily physician oversite and a maximum amount of therapy 
services in order to regain independence and return home safely. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography.  
 
You asked the Plan to pre-approve heart catheterization and ventriculography. You say that these services are 
medically necessary because the enrollee had a stress test that showed possible ischemia in left anterior 
descending artery (LAD) territory. The Plan denied your request. The Plan says these services are not 
medically necessary. The patient's medication regimen consists of levothyroxine, losartan, multivitamin, 
red yeast rice. The patient is not on any antianginal agents including beta-blocker, calcium channel blocker, 
long-acting nitrate. Electrocardiogram shows sinus bradycardia with first-degree atrioventricular block but no 
significant ischemic changes. Myocardial perfusion imaging is low risk with normal ejection fraction small 
area of possible ischemia. There is documentation for suspected coronary artery disease. There is no 
documentation for crescendo anginal or noninvasive stress imaging which is non-diagnostic. There is no 
documentation for prior percutaneous core intervention, high risk features on noninvasive testing, cardiogenic 
shock, elevated coronary calcium score, reduced ejection fraction, large territory of myocardium at risk on 
perfusion imaging, electrocardiographic changes with stress, multiple perfusion defects. There is no significant 
valvular heart disease.  
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 heart catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee's electrocardiogram shows sinus 
bradycardia with first-degree atrioventricular block but no significant ischemic changes. Myocardial perfusion 
imaging is low risk with normal ejection fraction small area of possible ischemia. The enrollee is not on any 
anti-anginal agents including beta-blocker, calcium channel blocker, long-acting nitrate. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization 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 heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and ventriculography.
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 this level of care. The Plan denied 
your request. The Plan says the enrollee's needs can be safely managed at the current facility until they are 
more stable for transfer to another 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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. While the medical records support 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 presently receiving an intensive level of care and appears to be too 
unstable to transfer to another facility. The enrollee has intermittent gastrointestinal bleeding, an extremely low 
platelet count, extremely low white blood cell count and is being treated for sepsis. In addition, there are no 
services available at the LTACH that are not currently available at the current facility. 
 
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: 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 you are requesting an expedited 
reconsideration for LTACH for complex medical necessity. The Plan denied your request. The Plan says that 
the request is not medically necessary. 
 
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 continues to require the management of multiple serious medical conditions even 
though their condition is relatively stable. The enrollee will require an additional stay of at least 25 more days 
at an inpatient level, with daily physician supervision and continuing advanced care that can be provided at an 
LTACH. The enrollee's attending physician has advocated for transfer to an LTACH for continuing 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF services are necessary for you to 
get therapy and regain your strength.  The Plan denied your request. The Plan says admission to a SNF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage for hyaluronans have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat series of injections may be allowed 
when: 
 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is documented in 
the medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Euflexxa have not been met. Specifically, the case record does not support that the last injection in 
a prior course was given at least 6 months ago. Therefore, we decided that the Plan does not have to pre-
approve treatment with Euflexxa (J7323).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing 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 the enrollee was admitted for a femur fracture after a fall. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. 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. 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: Favorable

 
We decided that the Plan has to pre-approve the lower extremity revascularization (37229, 37220, 37221, 
36247).  
 
You asked the Plan to pre-approve the lower extremity revascularization. You say that the enrollee has non-
healing ulcers, no pulses, and is in pain. You say that the enrollee has a wound that has not healed. The Plan 
denied your request. The Plan says that the lower extremity revascularization is not medically necessary. The 
Plan says there is no evidence of significant arterial occlusive disease at rest. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the lower extremity revascularization. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has diabetes, a large wound, and an abnormal pulse examination. 
The ankle brachial indexes (ABIs) are falsely elevated due to arterial calcinosis from the enrollee's diabetes. 
These falsely elevated pressures are not indicative of satisfactory perfusion. As a diabetic, the enrollee is at 
elevated risk for limb loss in addition to the risks posed by arterial insufficiency. In this case, angiography and 
possible intervention is appropriate and 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 lower extremity revascularization have been met. Therefore, we decided that 
the Plan has to pre-approve the lower extremity revascularization (37229, 37220, 37221, 36247).   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound-guided radiation therapy. You say that the requested services are 
a medical necessity for you. The Plan denied your request. The Plan says the requested services are 
experimental/investigational for your 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 ultrasound-guided radiation therapy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that ultrasound-guided radiation therapy is experimental/investigational for 
the clinical situation in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound-guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) infusion services (96365, 96366, 96521) 
provided May 22, 2023. 
 
You asked the Plan to pay for the 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 the definition of code 96365 is intravenous infusion, for 
therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 
96366 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each 
additional hour (List separately in addition to code for primary procedure). The definition of code 96521 is 
refilling and maintenance of portable pump.  
We asked our coder 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 services. Our reviewer found for code 96365, the 
documentation submitted was reviewed and does not meet criteria. The medical record describes intravenous 
insulin treatment provided for an outpatient on May 22, 2023. In this case, there is a more appropriate 
Healthcare Common Procedure Coding System (HCPCS) code that should be reported for service provided. 
For code 96366, the documentation submitted was reviewed and does not meet criteria. The medical record 
describes intravenous insulin treatment provided for an outpatient on May 22, 2023. In this case, there is a 
more appropriate HCPCS code that should be reported for service provided. For code 96521, the 
documentation submitted was reviewed and does not meet criteria. The medical record does not include 
documentation of refilling and maintenance of portable pump. Our reviewer was unable to cite report, as this 
procedure was not found in medical record. 
 
We looked at this coder'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 pay for the intravenous (IV) infusion services (96365, 96366, 96521) provided May 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network x-ray provided on January 
11, 2023. 
 
You asked the Plan to waive the deductible for an x-ray. You say that you believe that your paperwork states 
that x-rays are covered in full. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to outpatient diagnostic tests and 
therapeutic services. You have been asked to pay $83.46 towards the $250 2023 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $250 deductible which applies to outpatient diagnostic tests and therapeutic services.  This cost sharing is a contractual obligation that had not been met at the time an x-ray was received on January 
11, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-network x-ray 
provided on January 11, 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 was independent until he fell and now is 
in need of rehabilitation to gain strength and help with cognition. The Plan denied your request. The Plan says 
the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
skilled nursing 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 the enrollee was admitted for a concussion after a fall. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. 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. 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.