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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care to optimize 
level of functioning prior to returning home. The Plan denied your request. The Plan says that criteria for 
admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can 
be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that clinical documentation shows that the enrollee has active comorbidities and would be expected to 
require close medical supervision on an inpatient basis during rehabilitation. Evaluating therapists (physical 
and occupational) state that the enrollee would tolerate and benefit from three hours of therapy five days per 
week. Thus, IRF criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the intense therapy so they can 
return home safely. The Plan denied your request. The Plan says the criteria for IRF admission were not met 
and the enrollee's needs can be provided at a lower level of care like 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 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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OneOme RightMed pharmacogenomics test provided to 
the enrollee on February 14, 2022. 
 
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 with the information they have, they cannot determine how the enrollee came to the servicing 
provider, or whether the services are 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no specific clinical rationale for the ordered lab study. The review has determined that the 
services at issue in this were not case 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 pay for the OneOme RightMed pharmacogenomics test provided to the enrollee on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
April 8, 2022. 
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that CPT code 88342 was only billed 
once and does not have any coding conflicts. You say that this caused CPT code 88341 to be rejected but the 
claim was billed appropriately. The Plan denied your request. The Plan says payment for code 88342 is 
bundled into payment for code 88189. The Plan also says procedure code 88341 is an add-on code that is only 
eligible for payment if the primary procedure code is eligible for payment. 
 
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, we have confirmed that code 88342 
is a column II code to column I code 88189. Procedure code 88342 has not been billed with an appropriate 
modifier to bypass the edit. In addition, we have confirmed that code 88341 is an add-on code that is only 
eligible for payment if the primary procedure code is eligible for payment. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88342 and 88341 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the home BiPaP is not appropriate for meeting 
this enrollee's ventilatory requirements. The Plan denied your request. The Plan says the records do not show 
that the enrollee meets the Medicare requirements. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has obesity hypoventilation syndrome but there is no mention of thoracic restriction notwithstanding that fact, the provided primary source documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. The 
enrollee could be treated with a BiPAP (bilevel positive airway pressure) machine with AVAPS (average 
volume-assured pressure support) capability. The plan has indicated coverage for such a device is available 
upon request. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 21, 2022 billed with 
codes 81206, 81235, 81275, & 81210. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 21, 2022 billed with codes 81206, 81235, 81275, & 81210.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
with a bacterial skin infection (cellulitis) and bacteria in the bloodstream (bacteremia). You are now medically 
stable with 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 documentation shows that the enrollee has functional impairments requiring 
skilled physical therapy and occupational therapy, but no evidence that the enrollee would be expected to 
require close medical supervision on an inpatient basis during rehabilitation. 
 
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 pay for the radiology services provided on February 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you would like to appeal the denied claim. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
approved authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on February 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that being treated for repeat epidural steroid injection may 
be considered medically reasonable and necessary when the medical record documents at least 50% of 
sustained improvement in pain relief and/or improvement in function measured from baseline using the same 
scale for at least three months. 
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
the Medicare LCD criteria states 50% pain relief for at least 3 months. This was not achieved in this case. 
Therefore, the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has high risk prostate 
cancer. The Plan denied your request. The Plan says the enrollee's cancer is not a recurrence or metastasis. 
 
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 requested services. Our physician 
reviewer found that stereotactic body radiotherapy, delivering high fractional doses to the prostate in 3-5 
fractions is an emerging approach to the treatment of high-risk prostate cancer. The current literature supports 
SBRT as an option for monotherapy in select patients with high-risk disease. As a boost treatment in those with 
high-risk disease, however, SBRT is not standard and arguably remains investigational in terms of efficacy and 
toxicity. Therefore, the standard criteria would not be met. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stereotactic body radiation therapy (SBRT).
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. The Plan denied your request. The Plan says you do not have 
complex care needs that require a coordinated team approach. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for an ankle fracture after a fall. Your medical problems are stable. 
The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH services. The Plan denied your request. The Plan says the enrollee is currently receiving the 
proper care that they need in the hospital and there is no need to transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the documentation does not support that the enrollee has a need for 
complex medical treatment in a LTACH(e.g., multiple and prolonged intravenous therapies, monitoring of 
significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, 
complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites).   
 The enrollee does not require services at the LTACH that are not available at the acute care hospital or the 
skilled nursing facility. The requested treatments are not medically necessary at the LTACH level of care. The 
enrollee has improved medically and can receive further care at the current acute care hospital or a lower level 
of care when deemed 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) provided on December 30, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim was recently 
corrected and refiled. The Plan denied your request. The Plan says the corrected claim was not filed timely. 
 
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 the evaluation and management service was not filed until April 26, 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 the office visit (99205) provided on December 30, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enollee does not meet the criteria for coverage of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
requested use of Retacrit is not supported. Our physician reviewer found the use of Retacrit is not Food and 
Drug Administration-approved for treatment of anemia with inadequate iron stores. This use of Retacrit is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.