Persius/hicric huggingface dataset:
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested SNF services are not medically 
necessary, reasonable, and appropriate for the enrollee's condition. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiogram. 
 
You asked the Plan to pre-approve echocardiogram. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve echocardiogram. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is asymptomatic with stable cardiovascular status. The enrollee had an 
unremarkable Echocardiogram in July 2021. Asymptomatic enrollees should undergo follow up every one year, 
three years, and five years in case of severe, moderate and mild aortic stenosis respectively. The documentation 
does not support that the enrollee will benefit from repeating that testing.  Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of echocardiogram have not been met. Therefore, we decided that the Plan does 
not have to pre-approve echocardiogram.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that in order to return home, the IRF is 
where you can receive the care you need. The Plan denied your request. The Plan says the requested 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 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 enrollee may benefit from physical therapy 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0842) and accessories (E0955, 
E1007, E1012, E1020, E1028, E2311, E2313, E2361, E2377, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is 
unfortunately without a properly fitted mobility device and is a very high risk for skin breakdown, fall risk and 
rehospitalization. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis 
causing mobility limitation for a group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
bilateral leg amputation and relies on a manual wheelchair. The enrollees upper extremity strength is 3-/5. Per 
L33789, the enrollee does not have conditions requiring a group 3 power wheelchair. He relies on a power 
wheelchair and does not have skin breakdown. No catheter no spasms and has adequate strength to manage 
standard drive controls. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0842) and accessories (E0955, E1007, E1012, 
E1020, E1028, E2311, E2313, E2361, E2377, E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that bilevel positive airway pressure (BiPAP) has been 
considered and rules out. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose, and the needed therapy could be delivered by a BiPAP device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection, certolizumab pegol, 1 mg (code J0717) 
provided on November 1, 2022. 
 
You asked the Plan to pay for the injection, certolizumab pegol, 1 mg. You say that the injection, certolizumab 
pegol, 1 mg was medically necessary. The Plan denied your request. The Plan says this procedure code (J0717) 
has been billed and allowed the maximum number of times within a particular time period in accordance with 
Food and Drug Administration (FDA) standard dosing recommendation. 
 
The Plan must follow Medicare rules. The rules say that Medicare may cover the use of an FDA-approved drug 
or biological if it is safe and effective and otherwise reasonable and necessary for the patient. 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 injection, certolizumab pegol, 1 mg. Our 
reviewer says that the requested injection, certolizumab pegol, 1 mg is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that based on the medical records provided and the 
Medicare-approved major drug compendia there is no documentation that the certolizumab pegol at issue in 
this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for the 
enrollee. The provided medical records document the enrollee was being dosed with certolizumab pegol 200 
mg every two weeks for Crohn's disease. Based on the Medicare-approved major drug compendia, the dose of 
certolizumab pegol for Crohn's disease, active, moderate to severe is: "a) Initial dosage: 400 mg subQ (as 2 
injections of 200 mg) once and then repeat at weeks 2 and 4, b) Maintenance dosage: 400 mg subQ once every 
4 weeks if clinical response achieved, c) Concomitant therapy: May be used with non-biological disease 
modifying antirheumatic drugs may be used." There is no support in the compendia for the dosing schedule 
presented in the available 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 the injection, certolizumab pegol, 1 mg have not been met. Therefore, we 
decided that the Plan does not have to pay for an injection, certolizumab pegol, 1 mg (code J0717) provided on 
November 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on January 13, 2021. 
 
You asked the Plan to pay for practitioner visit. You say that you filed this claim in a timely manner. The Plan 
denied your request. The Plan says this claim was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for practitioner visit was not filed until March 29, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a practitioner visit provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for percutaneous image-guided neuromodulation 
or intravertebral procedures on the spine or spinal cord (code 01942) provided on November 8, 2022. 
 
You asked the Plan to pay for anesthesia for percutaneous image-guided neuromodulation or intravertebral 
procedures on the spine or spinal cord. You say that the anesthesia services were medically necessary. The Plan 
denied your request. The Plan says the requested anesthesia is not medically necessary and does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 anesthesia for percutaneous image-guided 
neuromodulation or intravertebral procedures on the spine or spinal cord. Our reviewer says that anesthesia for 
percutaneous image-guided neuromodulation or intravertebral procedures on the spine or spinal cord is not 
considered medically necessary. Our physician reviewer found that the enrollee is a 41-year-old female who 
underwent implantation of neuroelectrodes. A request was made for anesthesia for percutaneous image-guided 
neuromodulation or intravertebral procedures on the spine or spinal cord (code 01942) provided on  
November 8, 2022. Based on the provided documentation and coverage rules, the procedure code for the 
implantation includes anesthesia, therefore, the second procedure code for anesthesia is not supported and does 
not meet coverage criteria as it is redundant.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for percutaneous image-guided neuromodulation or intravertebral 
procedures on the spine or spinal cord have not been met. Therefore, we decided that the Plan does not have to 
pay for anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures on the spine or 
spinal cord (code 01942) provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient evidence to corroborate 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 99204 is office or other outpatient visit for the evaluation 
and management of a new 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 services. Our reviewer found that 
the enrollee was treated for dysphagia. The billed code requires a medically appropriate history and/or 
examination and moderate level of medical decision making.  In this case, the medical records submitted did 
not support moderate level of medical decision making or total time required of the code billed. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99204 billed for date of service October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a hospital bed (E0250) purchased on October 23, 2022. 
 
You asked the Plan to pay for a hospital bed. You say that the reimbursement was denied because the Plan 
didn't have the paperwork, but you did send it all in. The Plan denied your request. The Plan says that there was 
no authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for a hospital bed by a contract provider. The file does not show that the plan 
provided notice that a hospital bed would not be covered. Under Medicare rules, this means a hospital bed is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for a hospital bed (E0250) 
purchased on October 23, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not show that the enrollee is home bound (ambulating > 200ft) or that the enrollee 
continues to require the skill of a professional therapist in a home 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for the 
enrollee to improve their weight bearing tolerance and independence with ambulation using a walker as well as 
performance of self-care activities of daily living. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found a genicular nerve block is considered an experimental/investigational procedure and 
is the subject of ongoing clinical trials. Therefore, the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need 3.5 hours of physical therapy because you 
live alone and need assistance with walking and getting in and out of bed. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and your needs can be met in other settings. 
 
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 you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee requires care that could be provided 
at a SNF. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We requested medical records, but the plan did not send us any. Therefore, the 
Plan did not show that their denial is correct. 
 
Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) 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.