Persius/hicric huggingface dataset:
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 were admitted for 
non-surgical management of a hip fracture after a fall. Medical problems are stable. 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 this patient 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipilimumab 1 MG Injection. 
 
You asked the Plan to pre-approve the medication. You say that this would be used as monotherapy. The Plan 
denied your request. The Plan says this is an off label request and does not meet Medicare off-label policy 
guidelines 
 
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 the medication. Our physician reviewer 
found Ipilumumb as a single agent is not FDA approved for the treatment of urothelial or renal carcincoma. 
Major drug compendia does not support off-label use nor does the medical literature. Even in combination 
therapy with nivolumab indication is for fist line treatment and this patient is already on a PD-L1 inhibitor. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ipilimumab 1 MG Injection.
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 has multiple medical issues that require 
continued hospital care. The Plan denied your request. The Plan says there is no ongoing treatment of acute or 
acute on chronic medical conditions. 
 
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 the enrollee was admitted to the acute care hospital for management of myocardial infarction. He was 
discharged home with home health care, and has been receiving physical therapy in the home. His medical 
problems are stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that he 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on May 20, 2020.You asked the Plan to pay forthe CGP testing. 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 covered.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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on May 20, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 you are medically stable cardiac debility with no documented evidence of complex 
medical issues that require monitoring by an inpatient physical, medicine, and rehabilitation (PM&R) physician 
three times per week or need acute rehab nursing care. While you may benefit from continuing physical 
therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with 
therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 
care. Admission to IRF is not medically necessary based on lack of medical complexity and current functional 
status. Your rehab needs can be met at an alternate, low intensity level setting such as a skilled nursing facility 
(SNF) or in-home with 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 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 insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show the safety and efficacy of the 
device. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessaryas 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 careis not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for planned spinal fusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services (G0156) provided on March 19, 
2020. 
 
You asked the Plan to pay for home health aide services. You say that the enrollee needed 24-hour supervision 
to remain at home. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file does now show that skilled nursing or therapy services were provided during the dates of service at 
issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health aide services 
(G0156) provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) Hyperbaric Therapy Treatments. 
 
You asked the Plan to pre-approve the services. You say that the member has had open wounds for over a year 
and advanced wound care has not been effective. The Plan denied your request. The Plan says the doctor's 
notes do not say the member still has a bone infection in the foot. The Plan does not see that the member's 
current wounds are a result of diabetes and not vein disease. 
 
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 services. Our physician reviewer 
found the review indicates that Hyperbaric Oxygen has been requested (30 treatments) for Wagner 3 diabetic 
foot ulcers. Per the reviewed documentation, these foot ulcers often arise on the plantar surface and have 
abscess or bone infection that is refractory to conservative care. The patient had osteomyelitis a year ago and 
there is no current evidence of abscess, gangrene or osteomyelitis. The patient has diabetes, but the location of 
the wounds is consistent with venous disease and the clinical notes indicate that there is a dorsal foot pressure 
ulcer. The review has determined that there is no specific clinical rationale for the requested 30 hyperbaric 
oxygen treatments. The requested 30 treatments at issue in this case are not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thirty (30) Hyperbaric Therapy Treatments.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept System (CPT Codes: C9752, 22899 and 
C9753). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. It 
is not needed in this patient with chronic low back pain. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Intracept System (CPT Codes: C9752, 22899 and C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy duty hospital bed (E0304). 
 
You asked the Plan to pre-approve an extra heavy duty hospital bed (E0304). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that an extra heavy-duty hospital bed (E0302, E0304) is 
covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 
pounds. 
 
We looked at the file and Medicare rules. The file does not show that the enrollee's weight exceeds 600 pounds 
in order for Medicare coverage criteria to be met. Based on this information, we decided that Medicare rules 
for coverage of an extra heavy duty hospital bed (E0304) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an extra heavy duty hospital bed (E0304).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora bicycle.You asked the Plan to pay fora bicycle. You say that this should be covered because gyms are shutting down and are not clean.The Plan denied your request. The Plan says a bicycle is not included in the Wellness allowance benefits.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only for the specific programs listed above and in the Plan contract.The Plan's rules for coverage of gym benefits have not been met because a bicycle is not listed as a covered benefit under the Wellness Allowance.Therefore, we decided that the Plan does not have to pay fora bicycle.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
June 8, 2020. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you were admitted 
outpatient for gallbladder surgery and according to your benefits chart you should not owe a copayment. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $325 copayment for outpatient surgery services. Outpatient surgery services fall 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 waive the copayment for outpatient surgery services 
provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardant 360 genetic testing. 
 
You asked the Plan to pre-approve Guardant 360 genetic testing. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not have a definitive 
diagnosis of cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met.  
 
We looked at the file and Medicare rules. The file shows that the enrollee does not have either recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, we decided that the Plan does 
not have to pre-approve Guardant 360 genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Valsartan 320mg Tablet. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Valsartan 320mg Tablet.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says therapy needs can be safely met at a lower level of care in the subacute nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for encephalopathy. Medical problems are stable. 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. 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.