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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with a recurrent left foot infection after a great toe amputation. He was diagnosed with 
osteomyelitis and started on intravenous (IV) antibiotics. His sepsis has resolved and he has been successfully 
weaned from a ventilator and is stable on room air. His current care needs are IV antibiotics for another six 
weeks, basic wound care, and basic monitoring. The enrollee does not require services at the proposed LTACH 
that are not already available at the current facility. There are no services available at the proposed LTACH that 
the enrollee requires that are not already available and covered at the current facility. The LTACH services are 
not reasonable or 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical conditions are not complex or severe enough to require LTACH level of care.
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. You still require acute hospital level of care services and are receiving appropriate care at the present acute care hospital. At the time you are considered medically stable by the treating team you may be a candidate for care at a less intense level. Our physician reviewer found that you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose vein ligation surgery of the right leg. 
 
You asked the Plan to pre-approve varicose vein surgery. You say that you have gone to the emergency room 
multiple times already and cannot stand the pain anymore. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the records do not show any evidence of at least 3 
months of attempted and failed conservative management. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment of varicose veins of the lower 
extremities may be covered when the above clinical criteria have been met. 
 
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 varicose vein surgery. Our reviewer 
says that you do not meet the Medicare criteria for the requested surgery. Our physician reviewer found there is 
unsatisfactory documentation that you are having activity-limiting symptoms attributable to your varicose 
veins. Concerted efforts at conservative treatment are not documented. There is documentation that you are 
ambulating normally. Your input that your leg pain required emergency room visits suggests there may be a 
potentially serious alternative cause for your symptoms. The request calls for a rather extreme degree of 
treatment with open ligation and stripping of veins. There is no documentation of reflux in the veins targeted 
for stripping. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of varicose vein surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve varicose vein ligation surgery of the right leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve CPAP. 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 follows Medicare rules. Medicare rules say that CPAP is only covered for certain indications. 
 
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 CPAP. Our reviewer says that the 
documentation does not support that the requested CPAP is medically reasonable or necessary. Our physician 
reviewer found the Compliance Report covering April 17, 2020 to July 15, 2020 shows usage does not meet the 
minimum requirement of at least 4 hours a night for at least 70% of nights. Usage is insufficient for the 
treatment to be effective, and therefore, CPAP is considered 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 CPAP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve continuous positive airway pressure (CPAP) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel rendered on February 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure 
code 81479. 
 
The file shows that the panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the panel rendered on February 18, 2020.
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 the services can be safely received in other settings, for example: a skilled 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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will continue to require 
acute care before he's safe enough to transition to a lower level of care. The Plan denied your request. The Plan 
says the enrollee's current needs are being met in the acute setting. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the charges for the review/interpretation of international normalized 
ratio (INR) test result provided on February 4, 2020. 
 
You asked the Plan to waive the charges for the INR test interpretation. You say that you do not understand 
why you are being charged for this when lab testing is covered in full. The Plan denied your request. The Plan 
says that this is considered a specialist office visit so the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract says that lab testing is covered with no copayment. 
 
In this case, we find that it is not reasonable for an enrollee to expect to pay a specialist visit copayment when 
presenting for a lab test with only review of that lab test. This would be reasonably considered a lab service 
which is not subject to a copayment. Therefore, we decided that the Plan has to waive the charges for the 
review/interpretation of international normalized ratio (INR) test result provided on February 4, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
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 the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostate 
cancer. Proton beam therapy is not routine recommended for prostate cancer outside of a prospective clinical 
trial or registry. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Proton beam therapy is not the standard of care and 
is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dehydrated alcohol.
You asked the Plan to pre-approve the drug. You say that this is needed due to short gut syndrome. The Plan denied your request. The Plan says this cannot be approved since it is not FDA-approved.
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 the drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found this is not FDA-approved, and there is no documentation provided to justify an off-label use. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve dehydrated alcohol.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 enrollee's needs may be met 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 SNF service. 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services (CPT 99232) provided to the enrollee on 
March 19, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99232 is disallowed when submitted more than once. 
 
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 99232 is "Evaluation and Management services for an 
established patient for subsequent hospital care per day that includes at least two of the following: an expanded 
problem focused interval history, an expanded problem focused examination, and/or moderate 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
medical records provided do not include adequate documentation to support additional reimbursement of CPT 
99232. If claim denials based on these edits are appealed, contractors may pay UOS in excess of the MUE 
value, if there is adequate documentation of medical necessity of correctly reported units. The duplicate value 
assigned to this code is consistent with the current MUE value. In addition, code auditing logic allows for the 
reporting of one Evaluation and Management procedure per date of service. CPT specifically describes the 
instructions for selecting the appropriate level of E/M service to include the following steps: Identify the 
category and sub-category of service, Review the reporting instructions for the selected category or sub-
category, Select the appropriate level of E/M service based on the extent of history obtained, the extent of 
examination performed, and the complexity of medical decision making. CPT 99232 is disallowed when 
submitted more than once. 
 
 
 
 
 
 
 
 
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 pay for office visit services (CPT 99232) provided to the enrollee on March 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 there is no daily skilled care needed. 
 
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 your condition does not meet 
Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 home health aide services and 5 skilled nursing 
visits. 
 
You asked the Plan to pre-approve home health aide services and skilled nursing visits. 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. 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 aide services and skilled 
nursing visits. Our reviewer says that the documentation does not support that the Our physician reviewer 
found the documentation doesn?t support that you require skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary. You do not require skilled nursing or rehab services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have remained medically stable and 
requires further custodial care. Therefore, you do 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 home health aide services and skilled nursing visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 25 home health aide services and 5 skilled 
nursing visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Capecitabine 500mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary and should be approved. The Plan denied your request. The Plan says that the use of this drug requires a diagnosis of stage II, stage III, or metastatic colon cancer.
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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the literature indicates that Capecitabine has been heavily investigated in all colorectal cancer treatment settings. Although it was initially approved for use by the FDA in the adjuvant setting for stage III disease, the most robust data exist in the metastatic setting. Its off-label use is quickly growing and will continue to do so, pending the publication of a number of ongoing clinical trials, especially in the adjuvant and neoadjuvant settings. The review has determined that the documentation supports that the Capecitabine is medically reasonable and necessary for the enrollee. The documentation supports that the Capecitabine is safe and effective for the enrollee. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve Capecitabine 500mg tablet for the enrollee.
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.