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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says all the enrollees current needs should be addressed and monitored by 
the specialist physicians who are most familiar with the enrollee in the current hospital 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be currently still unstable and requires short-term 
additional acute care services that can safely be performed at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer and as it would not be clinically advantageous at this time. Completion of treatment at the current 
facility is recommended. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic non-small 
cell lung cancer (NSCLC) with progression while on Keytruda. A positron emission tomography 
(PET)/computed tomography (CT) scan on October 4, 2022 showed progression of disease with suspicious 
mediastinal and left supraclavicular nodes and subpleural lesion that has that has doubled in size. Keytruda in 
this setting is not supported by major drug compendia or medical literature for off-label use. The services are 
therefore 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 Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is 
restricted from providing services. 
 
The Plan must follow Medicare rules. Medicare rules say that section 1128 of the Social Security Act provides 
the authority to Medicare to exclude various health care providers from receiving payment under Medicare. 
When an exclusion is imposed, no payment is made to anyone for any items or services in any capacity 
furnished, ordered, or prescribed by an excluded party under the Medicare, Medicaid, and all federal health 
care programs. In addition, no payment is made to any business or facility, e.g., a hospital, that submits claims 
for payment of items or services provided, ordered, prescribed, or referred by an excluded party.  
 
We looked at the file and Medicare rules. The rendering provider has been excluded from receiving payment 
under Medicare. 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 services provided on April 8, 
2021.
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 requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 the patient has functional impairments but none that are complex enough to warrant 
interdisciplinary team management or intense therapy. IRF criteria not 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says based on 
Medicare guidelines your request for approval of continued admission in skilled nursing facility does not meet 
the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee presented to the acute hospital on October 9, 2022 with 
altered mental status and hypoxia. The enrollee was treated in the hospital, condition stabilized and was 
transferred to a skilled nursing facility for skilled nursing and therapy service on October 12, 2022. As of 
October 24, 2022 the enrollee was walking 170 feet with a front wheeled walker with contact guard to 
minimum assistance and was stand-by assist for transfers and minimum assist for some activities of daily 
living. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be performed at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 10, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on January 10, 2022.
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 based on the enrollee's current condition, functional 
deficits and comorbidities they need IRF services. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says that the clinical value and effectiveness of 
Keytruda in the setting of urothelial carcinoma that has experienced disease progression on PD-L1 inhibitor 
therapy have not been demonstrated in the peer-reviewed literature. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found use of this drug is supported by clinical 
research that appears in a CMS-approved medical journal (Gettinger SN, Wurtz A, Goldberg SB, et al. Clinical 
Features and Management of Acquired Resistance to PD-1 Axis Inhibitors in 26 Patients With Advanced Non-
Small Cell Lung Cancer. J Thorac Oncol 2018; 13:831.) and when there is progression of disease toe limited 
sites, amenable to radiation therapy, can continue Programmed death-ligand 1 (PD-L1) therapy. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a polysomnography (95811). 
 
You asked the Plan to pre-approve a polysomnography. You say that you need a facility based continuous 
positive airway pressure (CPAP) titration test done because your sleep apnea has gotten much worse over the 
last few years. The Plan denied your request. The Plan says that you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a Type I PSG is covered when used to aid the 
diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed 
attended in a sleep lab facility. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a polysomnography. Our reviewer says 
that an attended bilevel positive airway pressure (BiPAP) titration study is reasonable and medically necessary. 
Our physician reviewer found the enrollee has Obstructive Sleep Apnea (OSA). Our reviewer found that no 
effective continuous positive airway pressure (CPAP) could be found with positive airway pressure titration 
during the split-night study. Our physician reviewer also found that it is reasonable to perform a dedicated 
BiPAP titration sleep study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve a polysomnography (95811).  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this to get stronger. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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 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 you may need 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services for an office visit and 
an electrocardiogram, routine ECG provided on November 17, 2021. 
 
You asked the Plan to waive the copayment for physician's services for an office visit and an 
electrocardiogram, routine ECG. You say that a physicians assistant is not allowed to charge the full 
copayment amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 copayment for physician/practitioner services, including doctors office visits, for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician. Your contract with the Plan says you must pay a $20 copayment for other outpatient diagnostic 
tests -non-radiological diagnostic services. 
 
You have been asked to pay a $40 copayment for the office visit and a $15.37 copayment for the 
electrocardiogram, routine ECG because $15.37 is the allowable amount, which is less than the contractual 
copayment. 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 physician's services for an office visit and 
an electrocardiogram, routine ECG provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy supplies provided on June 14, 2022. 
 
You asked the Plan to pay for ostomy supplies. You say that the enrollee needs more supplies than the 
participating providers' limit. The Plan denied your request. The Plan says this provider does not participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for ostomy supplies provided on June 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested office visit. 
 
You asked the Plan to pre-approve an office visit. You say that you have a faithful history with these providers 
and you prefer to be seen by them for your revision surgery to the lumbar area. You say this facility is a 
progressive scholastic institute and they have the latest medical technology available. The Plan denied your 
request. The Plan says your notes do not show that you need a tertiary level care. It was determined that there 
was no medical necessity for this request. 
 
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 office visit.  Our reviewer 
says that the requested tertiary level of care physician's services is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that tertiary care is not medically needed in this case. This 
is a routine degenerative back condition and can be managed appropriately without tertiary 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 requested office visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the requested office visit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) provided on April 15, 
2022. 
 
You asked the Plan to pay for detection test by nucleic acid for multiple types of respiratory virus, multiple 
types or subtypes, 12-25 targets. You say that this testing was medically necessary. The Plan denied your 
request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of detection test by nucleic 
acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) 
provided on April 15, 2022.