Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from February 25, 
2020 to April 13, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that this code has been paid on other claims. The 
Plan denied your request. The Plan says this code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from 
February 25, 2020 to April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on March 16, 2020. 
 
You asked the Plan to pay for the services provided. You say that anesthesia was required due to fear of 
injection. The Plan denied your request. The Plan says the medical records do not establish the need for the 
sedation. 
 
The Plan follows Medicare rules. Medicare rules say that documentation must clearly establish the need for 
such sedation in the specific 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 services provided. Our physician 
reviewer found that the enrollee has a history of low back pain. She had been treated with medications, 
physical therapy and previous epidural steroid injections. In this case, the enrollee had no significant past 
medical history to warrant monitored anesthesia care (MAC). There was no documentation in the record 
indicating that it was medically necessary to have an anesthesiologist present during a lumbar epidural steroid 
injection (LESI). Medical necessity for an anesthesiologist to administer MAC/IV sedation was not clearly 
established. The review has determined that the anesthesia services performed were not medically necessary or 
reasonable for this enrollee to have IV sedation during the injection performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services provided on March 16, 2020.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care 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 above. 
 
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 medical records do not show that the complexity of the enrollee's nursing, 
medical, and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee requires physical therapy and occupational therapy services, but does not 
require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee 
requires the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility 
level appears to be more appropriate. 
 
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 Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve Image Guided Radiation Therapy (IGRT). You say that you would like the 
plan to reconsider their 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 Image Guided Radiation Therapy 
(IGRT). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has metastatic lung to bone. According to the 
NCCN radiation compendium for metastasis treatment, the options are EBRT, brachytherapy, IMRT, PBT, 
steriotactic brachytherapy, but not IGRT. 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 Image Guided Radiation Therapy (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living at home 
where you are treated for congestive heart failure and pulmonary hypertension. You have recently received 
home physical therapy services. Medical problems are stable. There are no medical problems that require 
inpatient management and there are no complex nursing or rehabilitation needs. You do not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the enrollee would benefit from a stay at an acute 
IRF. The Plan denied your request. The Plan says the IRF admission does not meet medical necessity. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. Our reviewer 
found that the enrollee's medical status does not currently require intensive physician and nursing oversight 
only in an IRF, and can be managed safely at a lower level of care. Our physician reviewer also found that the 
enrollee may benefit from multiple therapies such as physical and occupational therapy, but the documentation 
does not support that the enrollee's functional status requires an intensive rehabilitation therapy program 
provided only  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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Herceptin (in combination with Pertuzumab, paclitaxel, and 
carboplatin). 
 
You asked the Plan to pre-approve Herceptin. You say that you are appealing. The Plan denied your request. 
The Plan says that the denial of authorization for Herceptin is correct, because this drug combination is not 
FDA-approved or supported by any drug references. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Herceptin. Our reviewer says that you 
meet the Medicare criteria for use of Herceptin. Our physician reviewer found this drug is approved by the 
Food & Drug Administration (FDA) for your diagnosis. It is not uncommon to substitute paclitaxel for 
docetaxel given desired side-effect profile and risk to benefit profiles based on your comorbidities and desired 
side effects. The documentation supports that the requested drug is safe and effective and otherwise reasonable 
and necessary 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 Herceptin have been met. Therefore, we decided that the Plan has to pre-
approve use of Herceptin (in combination with Pertuzumab, paclitaxel, and carboplatin).  
 
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 stay was medically necessary. The Plan denied 
your request. The Plan says the stay 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 above 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 daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, the 
enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. The enrollee is ambulating 100 feet. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires or can tolerate an 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiography complete with Doppler (93306). 
 
You asked the Plan to pre-approve an echocardiography complete with Doppler. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 echocardiography complete with 
Doppler. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a cardiac magnetic resonance imaging (MRI) is ordered 
and this should provide similar information to that of an echocardiogram. Guidelines do not support 
echocardiographic imaging without knowing the outcome of the prior approved cardiac MRI. Coverage criteria 
for an echocardiogram are not met since much of the findings on echocardiography would be duplicative 
compared to the already approved cardiac MRI. 
 
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 echocardiography complete with Doppler have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an echocardiography complete with Doppler (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute care and 
does not require transfer to 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. The patient 
appears to be unstable with worsening status requiring additional acute care services for the short-term for 
oxygen weaning and treatment with what looks like a new pneumonia. The patient does not require any 
services at the LTACH that are not already available at the current facility. Continued care at the current 
facility is appropriate until stable enough for discharge to a lower level of care at a later date. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Vimpat. 
 
You asked the Plan to pre-approve Vimpat. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Vimpat. Our reviewer says that the 
documentation does support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has unspecified neurologic disorder, possibly autoimmune, and with seizure 
disorder, with daytime hypersomnolence. The documentation supports a very complex enrollee with complex 
diagnosis and complex symptomatology. It is medically reasonable to change to Vimpat as the Keppra may be 
causing symptoms that may be affecting diagnosis and treatment of the underlying condition. Therefore, the 
enrollee meets criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vimpat have been met. Therefore, we decided that the Plan has to pre-approve 
Vimpat.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a skilled nursing facility is not equipped to provide 
the level of care you need. The Plan denied your request. The Plan says you do not have a complexity that 
requires rehab physician supervision. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you were admitted for weakness and orthostatic hypotension. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
The medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
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.