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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is medically 
necessary. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current 
hospital, and there are no issues for which LTACH may offer a therapeutic advantage.  
 
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 that the acute hospital can provide for all the enrollee's present inpatient care needs 
and the Plan has stated that continued care in the short-term acute hospital will be covered as is medically indicated. Records do not support the need to transfer from one acute hospital to another. Continued care in the 
short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an 
inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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 LTACH 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 the enrollee clearly exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is recommended.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for injections of darbepoetin alfa and 
laboratory services provided from May 24, 2022, to August 15, 2023. 
 
You asked the Plan to waive the cost-sharing for darbepoetin alfa and lab services. You say that you had no 
idea the services would cost this much. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B Prescription Drugs and $10 copayment for lab services provided at an 
outpatient hospital facility. A summary of your cost-sharing amounts is below: 
 
Date of Service 
Service 
Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
May 24, 2022 Darbepoetin Alfa $898.10 20% coinsurance $179.62 
May 24, 2022 Lab Testing $14.31 $10 copayment $10 
November 8, 2022 Darbepoetin Alfa $898.10 20% coinsurance $179.62 
November 8, 2022 Lab Testing $14.31 $10 copayment $10 
December 6, 2022 Darbepoetin Alfa $898.10 20% coinsurance $179.62 
December 6, 2022 Lab Testing $14.31 $10 copayment $10 
August 15, 2023 Darbepoetin Alfa $1,826.21 20% coinsurance $365.24 
August 15, 2023 Lab Testing $14.55 $10 copayment $10 
Total    $944.10 
 
Therefore, your total cost-sharing responsibility is $944.10. 
 
You have been asked to pay 20% coinsurance for darbepoetin alfa and $10 copayment for lab services. These 
items/services fall within the Medicare Part B Prescription Drugs and Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit categories. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for 
injections of darbepoetin alfa and laboratory services provided from May 24, 2022, to August 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee cannot walk and have not 
received the proper physical therapy. The Plan denied your request. The Plan says the 100 days SNF benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from August 31, 2023, 
through December 26, 2023. The Plan has covered 100 days of SNF care. 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF care.
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 and their family are hoping for an IRF 
stay to regain as much function and strength as possible, while also having the proper physician management 
and 24/7 nursing care. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation 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 clinical documentation does not specify any complex functional impairments or 
active medical comorbidities; thus, the complexity of the enrollee's nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation supports ongoing physical and occupational therapy but does 
not warrant an intense therapy regimen in an IRF 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 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 sacroiliac radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac radiofrequency ablation. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is 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 sacroiliac radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy because of the wide variation in 
efficacy as reported in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve sacroiliac radiofrequency ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services. 
 
You asked the Plan to pre-approve the HHA services. You say that the enrollee has debility and states they 
cannot keep up with cleaning their home. You say the enrollee is in need of a caregiver who can help with light 
housekeeping and some meal preparation. The Plan denied your request. The Plan says the requested services 
does not require skilled medical or nursing care and would be considered custodial. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HHA services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the HHA 
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 the medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 enrollee 
was admitted for an ankle fracture after a fall. 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. There 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: 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 these services are deemed medically necessary. The 
Plan denied your request. The Plan says the required services can be provided in an alternate setting.  
 
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 documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Clinical documentation supports ongoing physical and occupational therapy but does not 
warrant an intense therapy regimen in an IRF setting. IRF criteria not met.  
 
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 the enrollee's medical management needs requires an 
inpatient rehabilitation stay and close physician supervision. 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 an open sacroiliac joint fusion with associated allograft, 
computerized navigation, and bone marrow aspirate. 
 
You asked the Plan to pre-approve an open sacroiliac joint fusion with associated allograft, computerized 
navigation, and bone marrow aspirate. You say that the enrollee is in severe pain and this procedure can greatly 
affect the enrollee ability to regain maximum function. You say that the enrollee has tried physical therapy, 
injections, medications, and external fixator with improvement, but it was only temporary. The Plan denied your request. The Plan says an open sacroiliac joint fusion with associated allograft, computerized navigation, 
and bone marrow aspirate 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 an open sacroiliac joint fusion with 
associated allograft, computerized navigation, and bone marrow aspirate. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of infection, tumor, or prior external fixation. Therefore, the request is not 
medically reasonable and 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 an open sacroiliac joint fusion with associated allograft, computerized 
navigation, and bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an open sacroiliac joint fusion with associated allograft, computerized navigation, and bone 
marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the SNF stay provided from June 1, 2023, 
to July 8, 2023. 
 
You asked the Plan to reduce the copayment for the SNF stay. You say that you do not believe your cost share 
amount is correct. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 a 
day copayment for days one through 20 of each skilled nursing facility admission per benefit period, a $150 
copayment a day copayment for days 21 through 44 per benefit period, and a $0 a day copayment for days 45 
through 100 per benefit period.  You have been asked to pay a total of $2,700 for the SNF stay. Your SNF stay was a total of 38 days, however 
you were not charged for days one through 20. Therefore, you were left with a balance of 18 days (38 days  
20 days = 18 days). You were billed 18 days x $150 copayment = $2,700 total copayment. This item/service 
falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for the SNF stay provided from June 1, 2023, to July 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetes supplies (A4239) provided on October 10, 2023. 
 
You asked the Plan to pay for the diabetes supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Neither the ship 
date nor delivery date match the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
diabetes supplies (A4239) provided on October 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 provided on April 3, 2023. 
 
You asked the Plan to pay for procedure code 87086. 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 supported. 
 
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 87086 is Culture, bacterial; quantitative colony count, 
urine. 
 
We find that CPT code 87086 is not supported in the medical record. Specifically, the records show results for 
a urinalysis and not a urine culture as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87086 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87086 provided on April 3, 2023.