Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve an injection, oxaliplatin, 0.5 mg (J9263) and an injection, 
pembrolizumab, 1 mg (J9271). 
 
You asked the Plan to pre-approve drug injections. You say that the enrollee is diagnosed with HER2 
overexpression positive metastatic stage IV gastroesophageal adenocarcinoma for first-line therapy. The Plan 
denied your request. The Plan says that the use of oxaliplatin (also called Eloxatin) and pembrolizumab (also 
called Keytruda) for HER2 overexpression positive metastatic stage IV gastroesophageal adenocarcinoma is 
not FDA approved or listed in the Medicare approved sources. 
 
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 drug injections. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the requested drugs are supported by one of 
the major drug compendia and/or by clinical research that appears in a CMS-approved medical journal. 
Documentation shows that according to VP1-2023, pembrolizumab (pembro) plus chemotherapy (chemo) is 
used as first-line therapy for advanced HER2-negative gastric or gastroesophageal junction (G/GEJ) cancer; 
Phase III KEYNOTE-859 study, Annals of Oncology, February 16, 2023. The documentation supports that the 
requested drug is safe and effective and otherwise reasonable and necessary for this 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 drug injections have been met. Therefore, we decided that the Plan has to pre-
approve an injection, oxaliplatin, 0.5 mg (J9263) and an injection, pembrolizumab, 1 mg (J9271).  
 
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 are appealing the denial. 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pulmonary edema, congestive heart failure, respiratory failure and acute kidney injury. Medical problems are 
stable. There are 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. Medically necessary care can be provided in a different 
level of care. 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. 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 the enrollee is medically stable and no acute rehab nursing needs are documented. 
The complexity of the enrollee's nursing and medical needs do not require an acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in an alternate 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee did not respond to an active therapy program. The 
enrollee is able to do a home exercise program. Continued input from a skilled therapist is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the records provided should support the 
necessity of the requested service in dispute The Plan denied your request. The Plan says the records provided 
do not show that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer 
says that the requested service is not medically necessary in this case. Our physician reviewer found in this 
case, the documentation does not indicate that the enrollee has severe neuromuscular disease or that they are 
incapable of standing up from a regular armchair or any chair in their home.  Additionally, it is not clear from 
the documentation that is available for review that the enrollee is able to ambulate once standing. 
  
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift mechanism (E0627).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on June 14, 2022. 
 
You asked the Plan to pay for IRF care. You say that this admission was medically necessary. The Plan denied 
your request. The Plan says an inpatient admission was 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 pay for 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 enrollees care needs could have been met 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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided on June 14, 2022.
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 are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
  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 have daily skilled therapy needs but do not 
require daily skilled nursing 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral hip magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that in this case, with advanced osteoarthritis diagnosed and plans for a total hip 
replacement, the MRI does not appear to be reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the patient has severe 
bilateral hip pain not refractive to conservative treatment. The x-rays show severe degenerative changes, total 
joint space loss, and cystic changes. Possible avascular necrosis would be considered, although unlikely. The 
patient is being considered for bilateral total hip arthroplasty. The request for this MRI is reasonable to assess 
for avascular necrosis or other pathology prior to planning the total hip replacement. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
bilateral hip magnetic resonance imaging (MRI).  
 
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 pay for inpatient hospital services rendered from February 28, 2022, 
to March 4, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim are supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the provided documentation did not show sufficient evidence of sepsis being present as there was no signs 
of a systemic infection causing a dysregulated response leading to organ failure which is required to meet 
Sepsis 3 criteria. Therefore, the DRG of 603 is more appropriate for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from February 28, 2022, to March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, 
followed by 5mg/kg every 4 weeks thereafter. 
 
You asked the Plan to pre-approve Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, followed by 
5mg/kg every 4 weeks thereafter. You say that the requested dosage of Nulojix at a dose of 10mg/kg every 2 
weeks for 4 doses, followed by 5mg/kg every 4 weeks thereafter is medically necessary. The Plan denied your 
request. The Plan says the requested dosage of Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, 
followed by 5mg/kg every 4 weeks thereafter is not medically necessary. The Plan has approved Nulojix at a 
dose of 5mg/kg on days 1, 15, 29, 43, and 57, followed by 5mg/kg every 28 days thereafter as a maintenance 
regimen. 
 
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 Nulojix at a dose of 10mg/kg every 2 
weeks for 4 doses, followed by 5mg/kg every 4 weeks thereafter. Our reviewer says that the requested dosage 
of Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, followed by 5mg/kg every 4 weeks thereafter is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee requires the requested drug for the prevention of kidney transplant rejection. The Food and Drug Administration has stated that the 
requested drug is indicated for the enrollee's condition. The medical records provided are insufficient to 
establish the medical necessity of the dose requested. The record indicates that the plan has approved a dose 
consistent with the prescribing directions. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, followed by 5mg/kg 
every 4 weeks thereafter have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Nulojix at a dose of 10mg/kg every 2 weeks for 4 doses, followed by 5mg/kg every 4 weeks thereafter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump. 
 
You asked the Plan to pre-approve external ambulatory infusion pump. You say that you are appealing wit 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet criteria for this 
pump. 
 
The Plan follows Medicare rules. Medicare rules state that subcutaneous insulin administration by an external 
ambulatory infusion pump may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve external ambulatory infusion pump. 
Our reviewer says that the enrollee does not meet criteria for use of this pump. Our physician reviewer found 
there is no documentation that the external insulin pump is medically reasonable and necessary. The records do 
not document the enrollee's C-peptide level is less than or equal to 200 percent of the lower limit of normal of 
the laboratory's measurement method. The enrollee's C-peptide level was 9.25ng/mL. Also, the records do not 
document a positive beta cell autoantibody test or prior use of an insulin 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 external ambulatory infusion pump have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an external ambulatory infusion pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on April 19, 2022, and April 
20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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".  
We asked our coder 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 use of code 99233 is 
not supported by the records provided. Our reviewer found that the record does not contain a detailed interval 
history and the medical decision making was not of high complexity for April 19, 2022. The plan appeared to 
be identical to that of the admission note with no new information or addition to the care plan. The record also 
does not support that the enrollee was unstable, developed a significant complication, or a significant new 
problem. The record also does not contain a detailed interval history or medical decision making of high 
complexity for April 20, 2022. The treatment plan included continuing the current regimen and several 
conditions were resolved/asymptomatic. The record also does not support that the patient was unstable, 
developed a significant complication, or a significant new problem. 
 
We looked at this coder'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 services (99233) provided on April 19, 2022, and April 20, 2022.