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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intense therapy and refuse to go to a 
nursing home. 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 that you do not need a physical medicine and rehabilitation physicians supervision 
three times per week for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current level with anxiety and fatigue, you do not need a therapy program consisting of at 
least three hours of therapy per day at least five days per week. You do not need an intensive therapy program 
with therapy three hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. An IRF admission is not medically necessary. While you may benefit from physical therapy 
and occupational therapy, your therapy needs can be provided safely in a low intensity 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 inpatient rehabilitation facility (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 services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatments and should only require 
short-term additional acute care hospital services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 are requesting an expedited 
reconsideration stating the enrollee currently meets LTACH admission criteria. The Plan denied your request. 
The Plan says criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Byooviz (Q5124). 
 You asked the Plan to pre-approve Byooviz. You say that you do not like to use Avastin on your patients 
because it is not Food and Drug Administration approved. You also say that this puts the enrollee at high risk to 
get eye infections, which can slow their treatment down. The Plan denied your request. The Plan says the 
enrollee does not have any stated contraindications to the preferred products, nor have they tried any of the 
preferred agents. The Plan also says that a rationale is not provided for use of the non-preferred product for 
safety or efficacy. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Byooviz. Our reviewer says that the 
enrollee does not meet the coverage criteria for Byooviz. Our physician reviewer found the Plan requires a trial 
of bevacizumab (Avastin) before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. Our reviewer also found that there is no documentation provided indicating that 
the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Byooviz have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Byooviz (Q5124).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair (PWC) with 
multiple power options (K0843) and accessories. 
 
You asked the Plan to pre-approve a group 2 PWC with multiple power options and accessories. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the member does not meet 
criteria for group 2 wheelchair and therefore related accessories are also not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 PWC is covered if the criteria listed in the 
Medicare Rules section is met. If the PWC base is not covered, then related accessories will be denied. 
 
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 group 2 PWC with multiple power 
options and accessories. Our reviewer says that the member does not need these items. Our physician reviewer 
found the documentation does not reveal that the patient is at high risk for development of a pressure ulcer, 
utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. The patient's upper extremity strength and functional ability as evidenced by being 
independent for feeding should be sufficient to control any power options through their own switches. 
 
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 group 2 PWC with multiple power options and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair 
(PWC) with multiple power options (K0843) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress and rails 
(E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed with mattress and rails. You say that you need 
this type of hospital bed. The Plan denied your request. The Plan says the documentation does not demonstrate 
that you require frequent changes in body position or have a need for immediate changes in body position.  
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed with 
mattress and rails. Our reviewer says that this item is not medically necessary. Our physician reviewer found 
that in this case, the documentation doesnt support that you have a condition that requires frequent positioning 
of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or avoid 
respiratory infections in a way that an ordinary bed is not able to. Thus, you do not meet criteria for a semi-
electric hospital bed. 
 
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 semi-electric hospital bed with mattress and rails have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress and 
rails (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service October 18, 2022. 
 
You asked the Plan to pay for code 99285. You say that the claim was billed appropriately, and the level of 
service is supported. The Plan denied your request. The Plan says code 99285 is not supported by the medical 
record, so the claim was downcoded to code 99284. 
 
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 99285 is the evaluation and management of a patient 
requires 3 key components including a comprehensive history, a comprehensive physical examination and 
medical decision making of high complexity. 
 
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 code 99285. Our reviewer says that code 99285 is not 
supported in the medical record. Our reviewer found the member is a 77-year-old female with a medical history 
including hypertension and end-stage renal disease on hemodialysis who presented to the emergency 
department (ED) from a healthcare facility for replacement of a malfunctioning feeding tube. While she was in 
the ED she received routine hemodialysis. The member remained medically stable and was discharged back to 
the nursing facility the same day. 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service October 18, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services rendered from April 11, 2022, to May 10, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records were sent in. The Plan denied your 
request. The Plan says that the documentation submitted did not support that the primary diagnosis billed on 
the claim as being the chief reason the enrollee required the home care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 supported by the medical records. Our reviewer found that the documentation available for 
review includes several skilled nursing visits that document patient and caregiver education regarding 
hypertension, medication management regarding hypertension and monitoring of vital signs including blood 
pressure. It appears that hypertension was the reason for skilled nursing visits. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
home health services rendered from April 11, 2022, to May 10, 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: 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 requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for 
admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to be unstable and requires additional acute care hospital 
services that can safely be administered at the current facility until more stable and appropriate for transfer. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH would not be clinically advantageous at this time and completion of 
treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and is currently unstable for transfer to an LTACH. 
 
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 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 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says you do not have subluxation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve the chiropractic services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
September 13, 2022, billed with codes 87798, 87801, 87653 and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urine PCR (polymerase chain reaction) panel provided on September 13, 2022, billed with codes 87798, 
87801, 87653 and 87481.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast imaging mammography provided on March 2, 2022. 
 
You asked the Plan to pay for a breast imaging mammography. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the Plan did not receive the primary carrier's 
explanation of benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary carrier's explanation of benefits. As the secondary insurer, the Plan cannot be held responsible for a 
breast imaging mammography until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for a breast imaging mammography provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) and supplies provided on 
November 1, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the records do not support the service that was 
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. Specifically, the Plan did not provide any rationale to support thedenial. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) and supplies 
provided on November 1, 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.