Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing related to end-stage renal disease (ESRD) 
provided on January 5, 2022. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that there is no contractual agreement in 
place which indicates that these codes are included in the dialysis payment. The Plan denied your request. The 
Plan says Medicare providers are not allowed to bill separately for lab testing rendered to an ESRD patient. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing related to end-stage renal disease (ESRD) provided on January 5, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for 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 do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 1, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 1, 2022.
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 this enrollee would be able to participate in and 
benefit from acute rehab as she was completely independent 
and active prior to hospitalization and has reasonable expectation for improvement while in rehab and return to 
her prior level of function. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
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 enrollee is a 62 year-old female who was admitted to the acute hospital on July 
27, 2022, with unresponsiveness, possible breakthrough seizure in the setting of COVID-19. Member was 
intubated on admission and extubated on July 30, 2022. Based on most recent progress note from August 9, 
2022, the member is on baseline 2L of oxygen and has improved bowel movements; member deemed stable for 
discharge. The member's prior level of function was documented as independent. Currently, member tolerated a 
23-minute physical therapy session in which she required moderate assistance for sit-to-stand for 1 min and 15 
seconds and was able to ambulate 3 feet with minimal assistance. Member is noted to be very shaky, with a 
heart rate of114 bpm and oxygen saturation of 96% post activity. The complexity of the patient's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says IRF care is not medically necessary because your needs can be 
met at a lower level of care. 
 
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 are a 75 year-old male with a history of Aphasia following cerebral infarction, hypothyroidism, dysphagia following cerebral following cerebral infarction, dysarthria, hemiplegia, 
Type II diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, heart attack, 
and chronic lower back pain. You are at home with diagnosis of Hemiplegia and hemiparesis following a 
stroke affecting your left non dominant side. You have been at an assisted living facility since June after a 
stroke in May. At that time, you received 20 days of IRF therapies and have since been receiving home health 
services and therapies. However, per your treating provider said that there was a several week gap in between 
IRF discharge and initiation of home health services and you had a significant decline in level of function. Prior 
to your previous IRF admission, you were unable to ambulate, with contact guard assist for bed mobility and 
functional transfers and set up for wheelchair mobility. 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 do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service January 22, 
2022, to February 3, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says the medical records do not support the 
billing of this code. 
 
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 keep components: a detailed 
interval history; a detailed examination; medical decision making of high complexity for services provided. . 
 
 
 
 
 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 99233. Our reviewer says that code 99233 is 
not supported for these dates of service. Our reviewer found for each date of service where this code was billed, 
the medical records indicate a lower level of complexity and medical decision making was present and a more 
appropriate code should have been reported. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 billed for dates of service January 22, 2022, to February 3, 
2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the requested IRF admission does not meet 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 the patient is a 69 year-old female with a history of atrial fibrillation and status post 
heart valve replacement in 2014 who was admitted to the hospital on July 22,2022, after a cardiac arrest. She 
had a second cardiac arrest while in the cardiac catheterization lab.  She was resuscitated and required 
intubation and  mechanical ventilatory support and placement of a pacemaker. She also required antibiotics for 
treatment for a urinary tract infection. She has been working with therapy at the hospital and are still very 
weak. She is able to walk about 15 feet with a walker and someone with a hand on her for safety. She also 
requires assistance with bathing. She is also having trouble swallowing now as well. She was independent with 
your self care and mobility before this hospital stay. The complexity of the patient's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test. 
 
You asked the Plan to pre-approve a hydrogen breath test. You say that your doctor believes the symptoms you 
have could be diagnosed with a breath test. The Plan denied your request. The Plan says your request cannot be 
approved because medical records were not received from your doctor to confirm why the test is being 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a hydrogen breath test. have been met. 
Medical records were not provided with this case. The Plan says they made multiple attempts to obtain these 
records from your doctor, but they were not received. Without this information, we cannot determine if the 
hydrogen breath test is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a 
hydrogen breath test.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (93880) provided on March 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. You say that your association has no opportunity to pre-authorize 
services and therefore, you should not be penalized. The Plan denied your request. The Plan says the services 
were not referred by a network provider or rendered in a participating facility. The services were not urgent or 
emergent and were not approved of in advance. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an ultrasound (93880) provided on March 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye examination (92004). 
 
You asked the Plan to pre-approve a medical eye examination. You say that you want a second opinion. The 
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency 
limit of one every year.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a medical eye examination have not been met. Specifically, the records shows that you received an 
eye examination on June 14, 2022. Therefore, we decided that the Plan does not have to pre-approve a medical 
eye examination (92004).
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 the enrollee was discharged to skilled nursing and 
lost the progress that was made. The enrollee needs to continue therapy so he can go home. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our physician reviewer found 
daily skilled services are not necessary. Our physician reviewer found that the medical records do not 
document that you require services on an inpatient basis, only in a skilled nursing 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve atezolizumab (Tecentriq) (J9022) and bevacizumab-bvzr (Zirabev) 
(Q5118). 
 
You asked the Plan to pre-approve Tecentriq and Zirabev. You say that the requested regimen is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested treatment is not in 
the order consistent with your health plan policy. 
 
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 Tecentriq and Zirabev. Our reviewer 
says that the requested regimen of Tecentriq and Zirabev is medically necessary. Our physician reviewer found 
the provided documentation indicates that the enrollee has previously been treated with tyrosine kinase 
inhibitors (TKI) inhibitor, Nexavar. Therefore, the reviewer found that immunotherapy with the requested 
drugs, Tecentriq and Zirabev, is medically reasonable and 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 Tecentriq and Zirabev have been met. Therefore, we decided that the Plan has 
to pre-approve atezolizumab (Tecentriq) (J9022) and bevacizumab-bvzr (Zirabev) (Q5118).  
 
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.