Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services (99205) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the oncology services. You say that this service is medically necessary. You 
are seeing specialists at the same hospital and would like to use the out-of-network provider. The Plan denied 
your request. The Plan says the services are not emergent. There are network providers available that can 
provide this service. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that a continued inpatient stay is 
medically necessary. The Plan denied your request. The Plan says the enrollee's presentation has improved to 
the extent that her treatment can be transitioned safely and collectively to ongoing care in he outpatient setting. 
 
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 pre-approve inpatient psychiatric care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric hospitalization on August 16, 2022, with Schizoaffective Disorder, Depressed 
Type and Borderline Personality Disorder. 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. The enrollee was compliant with treatment while not showing any acute threats to safety. 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 beyond the dates in question as she did not have dangerousness to self or 
others and was compliant with her treatment. 
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
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 requesting reconsideration as you have no 
one at home to assist you with your daily living without hurting yourself. The Plan denied your request. The 
Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting 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 you were admitted to the acute hospital on September 14, 2022 with a right heel 
wound with osteomyelitis. You were treated in the hospital with intravenous antibiotics, plastic surgery, 
debridement, skin grafting and a wound vacuum device and your condition has stabilized. You are at non-
weight bearing with the right lower extremity and are weak and deconditioned and working with physical and 
occupational therapy. You are non-ambulatory and are at minimum assist for transfers and some activities of 
daily living. Therapy notes indicate you tolerate 10-20 minutes of treatment with multiple rests. You otherwise 
are reported to be medically stable for discharge on outpatient medications. There are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that you require intense therapy; therefore, you do not 
meet IRF criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient admission is a medical necessity. The 
Plan denied your request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility 
services you are requesting 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 your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric visits provided on May 5, 2022, to May 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric visits. You say that the services have been essential for your 
emotional health. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
psychiatric visits. We found no exception that would require the Plan to pay for the psychiatric visits. The 
records provided for review do not show that the psychiatric visits were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the psychiatric visits provided on May 5, 2022, to May 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home COVID-19 tests you purchased on December 22, 
2021. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that you were told by the Plan representative 
that these tests were covered. The Plan denied your request. The Plan says you purchased these tests prior to 
the date when these were covered by Medicare. The Plan also claims that there are no phone calls on record 
prior to you purchasing these tests showing that you were advised by a Plan rep that these would be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may cover home 
COVID-19 tests as a supplemental benefit starting January 15, 2022, or prior depending on the specific benefits 
offered by the Plan. In this case, your plan had no supplemental benefit for coverage of these home tests prior 
to January 15, 2022.  You purchased the tests in question prior to that date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home COVID-19 tests have not been met. Therefore, we decided that the Plan does not have to 
pay for home COVID-19 tests you purchased on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel (80050) provided on January 15, 2021. 
 
You asked the Plan to pay for a general health panel. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel 
(80050) provided on January 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or 
hospice settings, each 15 minutes (CPT code G0156 x4). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are no skilled services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 home health services. Our physician 
reviewer found the clinical documentation does not show that there is a physician/provider face to face order 
for medically necessary services or that designates patient as home bound; thus, home health aide services are 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 
minutes (CPT code G0156 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on March 23, 2022. 
 
You asked the Plan to pay for these services. You say that you do not believe this bill is correct. The Plan 
denied your request. The Plan says the services billed were not related to manual manipulation 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 pay for chiropractic 
services provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zyprexa Tab. 
 
You asked the Plan to pre-approve Zyprexa Tab. You say that the enrollee has major mood disturbances and 
behavioral issues related to his oncology diagnosis. The Plan denied your request. The Plan says the requested 
drug is an oral self-administered drug and does not fall under Part B coverage. The enrollee does not have 
pharmacy (drug) benefits administered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zyprexa Tab.  
 Benefits for Zyprexa Tab may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab 1mg injection. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug for non-small cell lung cancer (NSCLC) is not FDA-approved or 
listed in any of applicable compendia. 
 
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 the services. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found that Food and Drug 
Administration (FDA) approval for first-line, single-agent treatment of nonsmall cell lung cancer (NSCLC) in 
patients with stage III NSCLC (who are not candidates for surgical resection or definitive chemoradiation) or in 
patients with metastatic NSCLC, and with tumors with PD-L1 expression (tumor proportion score [TPS] =1%), 
as determined by an approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic 
lymphoma kinase (ALK) genomic tumor aberrations. This patient has no PDL1 testing. Per the National 
Comprehensive Cancer Network (NCCN) guidelines repeat biopsy should be performed or treated as if not 
drive mutation. The service is not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pembrolizumab 1mg injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven (7) units of procedure code 96375 billed for date of 
service November 23, 2021. 
 
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 this service is not supported as billed. 
 
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 86375 is "Therapeutic, prophylactic, or diagnostic 
injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List 
separately in addition to code for primary procedure)." 
 
 
 
 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 the records do not support the use of 
seven units of this service. 
 
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 seven (7) units of procedure code 96375 billed for date of service November 23, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 29, 2021, through 
December 28, 2021, billed with code 1JA11. 
 
You asked the Plan to pay for the home health services as billed. You say that you cannot find any reason that 
the billed code is not correct. The Plan denied your request. The Plan says that the code billed on the claim was 
invalid on the date of service. 
 
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. We find that the HIPPS code that was used on this claim was valid for the date 
of service based on the Medicare HIPPS master list for home health services beyond January 1, 2020. The Plan 
has not provided any other cogent argument to explain why the HIPPS code reported is invalid. We find that 
the denial is not substantiated. Therefore, we decided that the Plan has to pay for the home health services 
provided from November 29, 2021, through December 28, 2021, billed with code 1JA11.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve prosthetic. You say that it is medically necessary. The Plan denied your 
request. The Plan says the requested item is considered experimental and investigational and is not covered by 
Medicare. 
 
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 prosthetic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a review of the literature showed a federally funded randomized controlled trial which did not 
show clinically significant benefit of the VASS system over other prosthesis. Per Medicare program Integrity 
Manual Chapter 13 section 13.5.4, the device is not medically necessary as it exceeds what is reasonable and 
necessary to meet the enrollee's needs. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management and 
moisture evacuation system (L5781).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 25, 2021, to December 31, 2021. 
 
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 the DRG was not supported.  
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 193. 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 services. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found that treatment was inconsistent with acute 
respiratory failure. There was no documentation of an administration of oxygen, 5L or more or a provision of 
bilateral positive airway pressure (BiPAP) and/or mechanical ventilation. The review has determined that the 
records do not support the billing of DRG 193.  
 
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 provided to the enrollee from December 25, 2021, to December 31, 2021.