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 an acute inpatient rehabilitation stay is needed for 
the enrollee to maximize their potential to return to their previous level of independence. 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 complexity of the enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing (SPECT). 
 
You asked the Plan to pre-approve radionuclide stress testing (SPECT). You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 radionuclide stress testing (SPECT). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
insufficient documentation to support the medical necessity for the requested cardiac imaging study in this 
patient'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 radionuclide stress testing (SPECT). have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radionuclide stress testing (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation. 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that the requested procedure is 
medically necessary. The Plan denied your request. The Plan says the procedure requested does not meet the 
requirements for approval. 
 
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 a genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the record indicates that the enrollee has osteoarthritis of knees. There 
is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested 
service. The records provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The requested service is not recommended, as the elements of the 
coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lens gas permeable (V5231) and contact lens 
fitting (92313).  
You asked the Plan to pre-approve contact lens gas permeable (V5231) and contact lens fitting (92313). You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says neither 
Medicare nor the Medicare Advantage health plan covers this.  
 
The Plan follows Medicare rules. Medicare rules say that when the PROSE device is used for any conditions 
other than those listed above, the device must be coded with HCPCS code V2531 (CONTACT LENS, 
SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)) and is 
subject to the Medicare refractive lens statutory coverage exclusion. 
 
The rules also say that Refractive procedures are not covered even when done in connection with otherwise 
covered diagnosis or treatment of illness or injury. 
 
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 contact lens gas permeable (V5231) and 
contact lens fitting (92313). Our reviewer says that you do not meet the criteria for contact lens gas permeable 
(V5231) and contact lens fitting (92313). Our physician reviewer found the enrollee does not meet any of the 
conditions required for the gas permeable contact lenses or the contact lens fitting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of contact lens gas permeable (V5231) and contact lens fitting (92313) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve contact lens gas permeable 
(V5231) and contact lens fitting (92313).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 to be admitted to an IRF to 
receive the necessary help to recover properly. The Plan denied your request. The Plan says the enrollee has not 
met criteria 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is complex and fragile. However, the medical record significantly complies with 
the various documentation requirements for an IRF admission. There is every reason to expect the enrollee will 
participate in and benefit from the IRF level services, to include at minimum physical therapy, occupational 
therapy, physician oversight of polypharmacy, and case manager coordination of any additional services the 
enrollee may need to make a sustainable return home as well as avoid further preventable readmissions to the 
acute hospital. The requested IRF admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires an LTACH admission. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH 
admission. 
 
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 there are no services available at the LTACH level, which the enrollee requires, that 
are not available at the health care setting being offered by the Plan. As there are offered alternatives, an 
LTACH admission is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration as 
the enrollee currently meets IRF criteria. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in an inpatient rehabilitation 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 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 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. 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. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement; however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 
three visits weekly to regain or maintain their functional status. The enrollee can receive further services at a 
lower 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 fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve immunotherapy. 
 
You asked the Plan to pre-approve immunotherapy. You say that you used to get them in Colorado, and it is 
getting worse, so you need them. You have PVC condition, and they prescribed them as it was necessary, The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
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 immunotherapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a previous history of immunotherapy and has failed treatment with 
antihistamines and nasal steroids. The review has determined that the items/services at issue in this case are 
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 immunotherapy. have been met. Therefore, we decided that the Plan has to pre-
approve immunotherapy.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says you have not tried and failed the alternative medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of Infed and 
Venofer before they will approve the requested drug Feraheme. Based on the medical records provided there is 
no indication that you have tried and failed the required drugs. Based on the medical records provided and the 
Medicare-approved major drug compendia there is no indication that the Plan's required drugs would likely be 
less effective or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has improved 
enough to be eligible for transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate care and is unstable for transfer to 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 being provided by the Plan. Transfer to an LTACH is not medically necessary as the 
enrollee is not yet stable and it would not be clinically advantageous.  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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy and you are a fall risk. You say 
that you are also at risk for multiple illnesses. The Plan denied your request. The Plan says you do not meet 
Medicare guidelines for services in an inpatient rehabilitation 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical or occupational therapy, at an intensive rehabilitation 
therapy program. You continue to have a need for skilled therapy however, the documentation doesnt support 
that you meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least three visits weekly to regain or maintain your functional status. You 
can receive further services at a lower 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 were trying to get into rehab for a few weeks to 
help get your leg recovered. 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 complexity of your nursing, medical and rehabilitation can be provided in a 
lower level of care and 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 30, 2022, to 
November 10, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that G93.41 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says G93.41 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
In this case, you billed the inpatient services provided with secondary diagnosis G93.41, defined as metabolic 
encephalopathy. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that secondary diagnosis G93.41 is not supported in 
the documentation. Our physician reviewer found the 89-year-old enrollee presented with low back pain and a 
history of a fall one month prior requiring vertebroplasty procedure for spinal fractures. A urinary tract 
infection (UTI) was suspected on evaluation based on mildly positive urinalysis. They were started on 
antibiotics and fluids and were noted to be alert and oriented to person, place, and time on admission. They 
were documented to have a period of confusion and combativeness, requiring Haldol. Other notes described the 
enrollee being only oriented to person and place, but that this was closer to their baseline. Following full 
workup, there was no clear cause of their confusion identified in the documentation, particularly a metabolic 
dysfunction.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 30, 2022, to November 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.