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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need a higher level of rehabilitation than is 
available at the current facility. The Plan denied your request. The Plan says you do not meet the criteria for an 
IRF admission. 
 
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 surgical repair of a hip fracture and patellar fracture after a fall and were transferred to skilled nursing care on 
March 26, 2023. Your problems are stable, and 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 you may have a need for physical therapy 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter insertion tray (A4354 x 300 per month), and 
straight tip urine catheter (A4351 x 300 per month). 
 
You asked the Plan to pre-approve catheter supplies. You say that you need these supplies as you are about to 
run out. The Plan denied your request. The Plan says the supplies are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that catheter supplies may be covered when 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 catheter supplies. Our reviewer says 
that the requested catheter supplies are not medically necessary. Our physician reviewer found the 
documentation indicates that the enrollee uses 150 to 210 intermittent catheters per month. The reviewer found 
that the documentation does not indicate the enrollee resides in a nursing home or is immunosuppressed. The 
documentation does not indicate the enrollee has radiologically documented vesico-ureteral reflux while on a 
program of intermittent catheterization, is a spinal cord injured female with neurogenic bladder who is 
pregnant, nor does the enrollee have distinct, recurrent urinary tract infections, while on a program of sterile 
intermittent catheterization. The documentation indicates the enrollee does not use indwelling catheters, so 
insertion trays are not necessary. Therefore, the reviewer found that the requested catheter supplies are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheter supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve catheter insertion tray (A4354 x 300 per month), and straight tip urine catheter (A4351 
x 300 per month).
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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs can, as a practical matter, be provided 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 62370 and J7999 provided on October 26, 2022. 
 
You asked the Plan to pay for codes 62370 and J7999. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services are not payable as billed. 
 
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 Local Coverage Article (LCA) 
A54100 and A56778 have billing criteria for implantable infusion pumps. However, LCA A54100 and A56778 
are not valid for the state of Missouri. Therefore, LCA A54100 and A56778 cannot be used for decision 
rationale. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for codes 62370 and J7999 provided on October 26, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Abraxane (J9264). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
treatment of cancer. The Plan denied your request. The Plan says that the accepted use of this drug in 
combination with Keytruda (pembrolizumab) for the enrollee's condition requires: has squamous histology 
where Abraxane (nab-paclitaxel) and Keytruda (pembrolizumab) will be given in combination with 
carboplatin. The Plan states the enrollee does not meet these requirements and the information the Plan has 
says the enrollee will be receiving Abraxane (single agent) with Keytruda only. 
 
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 the medication. Our physician reviewer 
found the requested use of Abraxane is not FDA-approved for the enrollees diagnosis. The use is supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journals because it is not uncommon to drop the carboplatin if the provider 
feels the medication would not be tolerated. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Abraxane (J9264).  
 
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 the placement of a deep brain stimulator and pulse 
generator (61885 and 61886). 
 
You asked the Plan to pre-approve the services. You say that you have been treating the enrollee since 2014 
and they have frequent seizures that increase the enrollee's change of sudden death. You state after careful 
evaluation the best treatment is deep brain stimulation. The Plan denied your request. The Plan says the 
Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. The enrollee's diagnosis is epilepsy is not a supported diagnosis for this treatment based on Medicare 
guidelines. Therefore, we decided that the Plan does not have to pre-approve the placement of a deep brain 
stimulator and pulse generator (61885 and 61886).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 37224. We decided that the Plan does not have to pay 
for procedure codes 75625 and 75710.  
 
You asked the Plan to pay for procedure codes 37224, 75625 and 75710 billed for date of service June 2, 2022.. 
You say that the services at issue have been billed correctly. The Plan says that the records provided do not 
support the services billed. 
 
  We decided that the Plan has to pay for procedure code 37224.  
 
The Plan follows 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 37224 is: Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. 
 
We asked our coder 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 procedure code 37224. Our reviewer says 
that procedure code 37224 meets criteria for payment. Our coder reviewer found that the available 
documentation does support the use of procedure code 37224 as the femoral artery balloon angioplasty 
describes this procedure. 
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37224 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 37224.  
 
We also decided that the Plan does not have to pay for procedure codes 75625 and 75710. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We asked our coder 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 procedure codes 75625 and 75710. Our 
reviewer says that procedure codes 75625 and 75710 do not meet criteria for payment. Our coder reviewer 
found that the available documentation does not support the use of procedure code 75625 as there was no 
evidence that an abdominal aortography was performed. The documentation does not support the use of 
procedure 75710 as there is a more appropriate code that can be used to describe the procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75625 and 75710 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75625 and 75710. 
 
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 percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve ViaDisc procedure. You say that the injections are medically necessary. The 
Plan denied your request. The Plan says the requested ViaDisc procedure at L4-5 is not medically necessary for 
the enrollee at this time. 
 
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 ViaDisc procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic axial low back pain. She has had epidural steroid injections 
without much improvement as well as diagnostic medial branch blocks. She takes Flexeril and Ibuprofen for 
pain. Her MRI shows multi-level degenerative disc disease. This is considered an experimental/ investigational 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ViaDisc procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
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 are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet all the requirements for an LTACH admission. 
 
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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital care provided from September 
27, 2022, through October 26, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital care. You say that the stay was medically 
necessary. The Plan denied your request. The Plan says the stay was not medically necessary. 
 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 inpatient psychiatric hospital care. Our 
physician reviewer found there was no indication in the available medical records that your psychiatric 
symptoms could not be managed on a less restrictive basis as of October 18, 2022. You were noted to have 
confusion at your baseline mental status. You were not exhibiting any other significant symptoms such as 
psychosis or mania. You had no acute psychiatric issues that would require continued inpatient care. You have 
chronic symptoms. The available medical records do not support that inpatient care would have changed these 
symptoms or your current condition. You are chronically impaired due to major neurocognitive disorder and 
the continued inpatient hospital stay was not expected to improve your condition in a reasonable period of 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 inpatient psychiatric hospital care have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient psychiatric hospital care provided from September 27, 2022, 
through October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 provided on July 4, 2022. 
 
You asked the Plan to pay for procedure code 99236. You say that the medical records support the billing of 
code 99236. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99236. 
 
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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) requiring admission are of high severity. Typically, 55 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 procedure code 99236. Our reviewer says that the medical 
records do not support the billing of code 99236. Our reviewer found the documentation available for review 
does not support that the presenting problems were of high severity or that the medical decision was of high 
complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99236 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 provided on July 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
September 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 remains 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was admitted to the 
hospital for first-time seizures and was evaluated and treated for a fever and COVID infection. The 
documentation does not include a comprehensive history for the date of service in question. 
 
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 initial hospital care (procedure code 99223) rendered on September 12, 2022.