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 you believe the enrollee requires an acute 
rehabilitation facility to return to prior level of function. The Plan denied your request. The Plan says the 
enrollee's needs can be met 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 IRF admission and services.
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 you would benefit from long term acute 
care services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an LTACH 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. Our 
physician reviewer found that you are receiving appropriate care at the present acute care hospital. 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab. 
 
You asked the Plan to pre-approve Romosozumab. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Romosozumab. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of osteoporosis without current pathological fracture. The record does not 
indicate that you at high risk of fracture as defined as a history of osteoporotic fracture, or multiple risk factors 
for fracture; or the failure or are intolerance to other available osteoporosis therapy. Therefore, you do not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romosozumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Romosozumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and asthma with severe airway obstruction. He has obstructive sleep apnea (OSA) 
that is intolerant to continuous positive airway pressure (CPAP) therapy. An arterial blood gas (ABG) study on 
January 27, 2023 showed mild carbon dioxide retention. The circumstances of the ABG are not provided. The 
records do not support that criteria for coverage are met and the home ventilator 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 a home ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service October 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the use of the drug was medically necessary. 
The Plan denied your request. The Plan says that the code is included with minor procedure code 62323. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that coincides with 
the drug documented in the medical records. The drug in this case is separately payable. The Plan has not 
provided a Medicare rule that would indicate the drug should be included in the global surgery package. Based 
on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure code J3490 billed for date of service October 3, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standar of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies 
to support the use of this device. 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 a Vertiflex Superion spacer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you live alone and cannot take care of yourself. The 
Plan denied your request. The Plan says the enrollee no longer has skilled nursing facility needs. 
 
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 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINX procedure (43284). 
 
You asked the Plan to pre-approve a LINX procedure. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 a LINX procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have gastroesophageal reflux with esophagitis and a DeMeester score of 41. There is 
insufficient literature to support the safety and efficacy of the requested services for your condition.  The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested 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 a LINX procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a LINX procedure (43284).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99213) provided on May 3, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary/ The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this service is included in the 
global surgery package for code 20610. Based on this information, we decided that Medicare rules for coverage 
of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99213) provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large-volume, long-term, peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
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 been participating in physical 
therapy and needs assistance with activities of daily living. The Plan denied your request. The Plan says criteria 
for admission to the IRF setting have 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 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 clinical documentation shows that the enrollee has complex functional 
impairments however, no active medical comorbidities are specified. The complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Additionally, functional documentation 
does not show that the enrollee would tolerate an intense therapy regimen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not agree with the decision, and you do not 
want to be admitted into SNF. The Plan denied your request. The Plan says your needs can be met at a lower 
level of care such as skilled nursing facility (SNF), home with home health services or outpatient. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received from providers. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99233 and 99232 provided on May 17, 2022, to May 
23, 2022. 
 
You asked the Plan to pay for codes 99233 and 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
 The CPT Code Manual definition of code 99232 is Subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT codes 99233 and 99232 are not supported in the medical record. Specifically, the medical 
records submitted do not include documentation of evaluation and management note for the billed date of 
services. Therefore, codes 99233 and 99232 cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of codes 99233 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99233 and 99232 provided on May 17, 2022, to May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  
You asked the Plan to pre-approve the services. You say that it is not realistic to continue weekly occupational 
therapy for lymphedema treatments both from time perspective and the financial cost. The Plan denied your 
request. The Plan says a trial of the basic or non-calibrated device has not been completed. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document any lymphedema of the chest, trunk, or abdomen. As records 
do not document lymphedema of the chest, trunk or abdomen or trial and failure of a standard pneumatic 
compression pump, then it cannot be said that the enrollee has unique characteristics that would indicate a 
segmented pump over a standard pump. 
 
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 a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve additional inpatient mental health care beyond February 7, 2023. 
 
You asked the Plan to pre-approve additional inpatient mental health care. You say that the enrollee is meeting 
criteria, making medication changes, is not safe for discharge, and is psychotic and delusional. The Plan denied 
your request. The Plan says that you are not expected to improve any further with this level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case medical records were not provided with the case file. We sent a 
request to the Plan for relevant medical records for review. These records were not received. Without this 
information we are unable to review whether the Plans denial is appropriate.  Therefore, we decided that the 
Plan has to pre-approve additional inpatient mental health care beyond February 7, 2023.  
 
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.