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

 
We decided that the Plan does not have to pay for the inpatient psychiatric admission provided from June 1, 
2022, to July 20, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric admission provided from June 1, 2022, to July 20, 2022. 
You say that the enrollee meets inpatient criteria and required continued treatment. The Plan denied your 
request. The Plan says the request is not medically necessary because the records received show the enrollee's 
condition had improved and they were no longer a threat to themself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our 
physician reviewer found it was not expected this enrollee would improve in a reasonable period of time for the 
dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. Our 
reviewer also found that it did not appear medically necessary and reasonable to have psychiatric care provided 
at the acute inpatient level of care rather than 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 the inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient psychiatric admission provided from June 1, 2022, to July 
20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says you do not have any 
daily skilled nursing needs, your needs can be met at a lower level of care at home with supervision and home 
health services. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the enterolysis services coded 44005 provided on July 22, 2022. 
 
You asked the Plan to pay for the enterolysis services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that payment made according to Medicare allowable rate. 
 
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. Review of the file shows that the Plan has denied this code due to payment made 
according to Medicare allowable rate. The documentation shows that this code was not paid on the claim. The 
documentation did not include explanation on why this code was not paid. No other denial rationale was 
provided. Therefore, the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay 
for the enterolysis services coded 44005 provided on July 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a naturopathic doctor. 
 
You asked the Plan to pre-approve the evaluation and management service. You say that you want this to be 
covered. The Plan denied your request. The Plan says naturopath services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pre-approve a consultation with a naturopathic doctor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Phesgo (J9316). 
 
You asked the Plan to pre-approve Phesgo. You say that the enrollee does meet the criteria and Plan medical 
policy guidelines. You also say that the enrollee is not eligible for surgery due to their age. The Plan denied 
your request. The Plan says the clinical value and effectiveness of Phesgo without adjuvant chemotherapy in 
the setting of hormone receptor positive (HR+) and human epidermal growth factor receptor 2 positive 
(HER2+) breast cancer 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 Phesgo. Our reviewer says that Phesgo 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Phesgo is not FDA-approved for the enrollees diagnosis because it is not being used with chemotherapy. The 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the use is not 
listed as not indicated, not supported or not recommended in any of the compendia. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Phesgo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Phesgo (J9316).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested 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 complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has had a decline from their baseline level of function and would likely benefit from physical and occupational 
therapy, but they do not require the intensity of therapies provided on acute inpatient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit coded 99205 provided on March 29, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollee is a new patient. The Plan denied your 
request. The Plan says that this is not the correct code to be billed for an established patient. 
 
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. Review of the file shows that the Plan states that the enrollee was an established 
patient, and this is the incorrect code for this. The documentation did not include documentation to support that 
the enrollee was an established patient. No other rationale was provided. Therefore, the Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pay for the office visit coded 99205 
provided on March 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel (81286, 81404, 
81405, 81406, 81407 and 81439) provided on September 7, 2021. 
 You asked the Plan to pay for the hereditary cardiovascular screening panel. You say that this testing was 
medically necessary and reasonable. The Plan denied your request. The Plan says this genetic testing is not a 
covered screening under Medicare. Please note that Medicare defines a cardiovascular disease screening as a 
lipid panel (80061) which includes cholesterol, serum or whole blood, total (82465), lipoprotein, direct 
measurement; high density cholesterol (83718) and/or triglycerides (84478). 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the hereditary cardiovascular screening panel, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the hereditary cardiovascular screening panel (81286, 81404, 81405, 81406, 
81407 and 81439) provided on September 7, 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 it is medically necessary for your health to be 
admitted for inpatient rehabilitation, recommended by your therapist. The Plan denied your request. The Plan 
says your medical condition is stable, the notes do not show a need for close care face to face visit at least 3 
days a week from a physician specializing in the field or Physical Medicine and Rehabilitation. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehabilitation 
with daily physician management, 24-hour specialized rehab nursing, and intensive therapies to optimize 
mobility and strengthening while ensuring the restoration of functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says based on Medicare guidelines, the enrollee does not 
meet the requirements for admission to an IRF. 
 
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 and active medical issues however, therapy documentation does not show that the enrollee would 
tolerate 15 hours of therapy per week. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foresee Home age-related macular degeneration (AMD) 
Monitoring System to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Foresee Home AMD Monitoring System to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Foresee Home age-related macular degeneration (AMD) Monitoring System to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Yutiq injection (J7314) and eye drug administration 
(67028). 
 
You asked the Plan to pre-approve a Yutiq injection and administration. You say that this should be approved 
because the enrollee had approval from their previous insurance. You also say that the medication is helping 
with the enrollee's diagnosis, has been receiving this medication since July 2022, and has been receiving a 
positive response. The Plan denied your request. The Plan says there is no documentation provided to support 
the medical necessity of a repeat Yutiq injection at less than 36 months. 
 
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 a Yutiq injection and administration. 
Our physician reviewer found based on the medical records provided and the Medicare-approved major drug 
compendia, there is no documentation that the repeat Yutiq injection (J7314) at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee at this time. The Medicare-approved 
major drug compendia do not support the dosing of Yutiq injection more frequently than every 36 months. Our 
reviewer also found that there is no documentation that the repeat Yutiq injection (J7314) at issue in this case 
meets all Medicare criteria for safe and effective for the enrollee at this time. 
 
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 Yutiq injection and administration have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Yutiq injection (J7314) and eye drug administration (67028).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins in one extremity 
with 10-20 stab incisions (37765) and unlisted vascular procedure (37799). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee is having pain in their legs 
and are increasingly tender. The enrollee has been wearing the compression holes for 6 months now. The Plan 
denied your request. The Plan says the request does not meet the Medicare or the Plan's coverage criteria. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support the medical necessity of the procedure in 
question. The enrollees evaluation materials provided do not provide sufficient scope and clarity on which to 
support performance of a surgical procedure.  The degree and nature of symptoms (and efforts at/response to) 
conservative treatment is not clear, there is no assessment of arterial perfusion to the lower extremities, the 
noninvasive study requested by the provider is not included the materials such that deep vein thrombosis has 
not been ruled out and the presence or absence of reflux in the medical veins is not known, and a treatment plan 
is not articulated in the medical record provided.  Therefore, unable to overturn the health plans determination 
on the basis of medical necessity.    
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stab phlebectomy of varicose veins in one extremity with 10-20 stab incisions 
(37765) and unlisted vascular procedure (37799).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you were in the hospital twice in the past three 
weeks. You say that your oxygen was too low. You also say that you were in the intensive care unit (ICU) for 
three days. The Plan denied your request. The Plan says the requested device is 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 a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the record indicates that you 
have chronic respiratory failure from chronic obstructive pulmonary disease. The reviewer found that the 
documentation indicates you were successfully treated with bilevel positive airway pressure (BiPAP). The 
reviewer found that the provided documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. Therefore, the reviewer found that the requested ventilator is not 
medically reasonable or necessary in this case. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided on October 13, 
2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you believe this should be covered. The 
Plan denied your request. The Plan says this claim has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam CT capture (D0367) provided on October 13, 2022.