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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH and cannot be adequately cared for in her current condition at a SNF. The Plan denied 
your request. The Plan says the LTACH 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 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. All medically necessary care is being provided 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 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. The Plan denied your request. The Plan says 
admission to the LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered until the enrollee could discharge to a lower level of care. 
 
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 setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are 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: 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 inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says IRF is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as skilled nursing facility (SNF), home health or outpatient therapy. 
 
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 are no complex nursing or rehabilitation needs. While the enrollee has 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 left atrial appendage closure (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
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 LAAC. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found while there is reference to consideration of 
the LAAC, there is no documentation of performance of an evidence-based shared decision-making interaction 
with an independent non-interventional physician. As such, guidelines would not support implantation of a 
LAAC in this 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 LAAC have not been met. Specifically, there is no documentation of a shared 
decision-making interaction. Therefore, we decided that the Plan does not have to pre-approve left atrial 
appendage closure (LAAC) (33340).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 
You asked the Plan to pre-approve Darzalex. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Darzalex. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Daratumumab (Darzalex) is not FDA 
approved for the prevention of hemolytic anemia prior to allogenic stem cell transplant for acute myeloid 
leukemia (AML). Use is not supported by major drug compendia for this indication. A search of the literature 
shows that Daratumumab has been used for the treatment of acquired red cell aplasia from an ABO-
incompatible allogenic stem cell transplant but use for prevention is not supported by the medical literature. 
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 Darzalex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get good rehabilitation both occupational 
and physical therapy. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission 
were not met and the enrollee can receive the care they need in a skilled nursing facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth extractions to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve tooth extractions. You say that you cannot use your front teeth right now. 
The Plan denied your request. The Plan says services must be performed by a participating general dentist and 
services by a oral surgeon are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when performed by an oral surgeon. Tooth extraction may be covered 
when performed by a participating general dentist. Please contact the Plan for more information about your 
treatment options. Therefore, we decided that the Plan does not have to pre-approve tooth extractions to be 
performed by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is unsafe for you to go home once discharged 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 there is no documentation that you require the services on an inpatient basis, only in a 
SNF setting. Records do not support services in the home with home health care or in a long-term care facility 
on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the evaluation clearly shows that the 
enrollee is a fall risk and does not have the ability to self-propel. The Plan denied your request. The Plan says 
an independent mobility evaluation contradicts the original finding that the enrollee lacks the stamina and 
strength to self-propel. The second evaluation documents that the enrollee was witnessed self-propelling 
without issue. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file includes two mobility evaluations, the second of which contradicts the first on several points. The 
major point of conflict is that while the first evaluation indicates that the enrollee does not have the stamina or 
upper extremity strength to propel a manual wheelchair, the second evaluation indicates that the enrollee was 
witnessed self-propelling without difficulty. There is also a discrepancy in which the first evaluation endorses frequent falls while in the second, the enrollee denied ever having fallen. Given that there is not clear 
documentation that a manual wheelchair cannot be used, we find that the criteria for the requested PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vancomycin hydrochloride. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug is intended for patient self-administration and is not covered 
by the Part B benefit. 
 
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 Vancomycin hydrochloride.   
Benefits for the medication 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional visits for re-evaluation of occupational 
therapy established plan of care (97168). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that services that do not require the professional skills of a 
therapist to perform or supervise are not medically necessary, even if they are performed or supervised by a 
therapist, physician or non-physician practitioner (NPP). 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan.   
The enrollee had had prior therapy and the documentation does not reveal that the enrollee requires the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the enrollees current 
condition or to prevent or slow further deterioration. The therapists have provided caregiver training. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 additional visits for re-evaluation of occupational therapy established plan of care 
(97168).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for services provided on June 
11, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is an 
appropriate code for the billed service. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
 
 We find that CPT code 97530 is not supported in the medical record. The medical records provided show that 
the enrollee received services in the home from an occupational therapy assistant. There is a more 
comprehensive code available that describes the services provided. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97530 billed for services provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four hundred (400) intermittent urinary catheters, with 
insertion supplies (A4353). 
 
You asked the Plan to pre-approve urinary catheters. You say that you are out of catheterization supplies, and it 
is medically necessary for you to have them for use. The Plan denied your request. The Plan says the request 
for 400 catheter kits cannot be approved at this time by Medicare or your health plan. You are approved for 200 
catheter kits. 
 
The Plan must follow Medicare rules. Medicare rules say that 200 urinary catheters are allowed each month. 
 
We looked at the file and Medicare rules. The LCD confirms that you receive a maximum quantity of 200 
urinary catheters per month. Based on this information, we decided that Medicare rules for coverage of urinary 
catheters have not been met. Therefore, we decided that the Plan does not have to pre-approve four hundred 
(400) intermittent urinary catheters, with insertion supplies (A4353).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 12, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it has not yet been three months since the last injection. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the most recent transforaminal epidural steroid injection was 7/21/22. The provider has 
requested a repeat injection at the same level using the same approach. The original request was 9/13/22, which 
is less than three months from this injection. 
 
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 epidural steroid injections for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for initial observation care provided on April 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that no modifiers are required. The Plan denied 
your request. The Plan says that the service was billed incorrectly. 
 
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. 
 
We looked at the file and the rules. The Plan denied CPT code 99219 as it was billed incorrectly. The Plan does 
not specify what was incorrect about the billing. The Plan cites Medicare rules pertaining to formats for 
submitting claims to Medicare. However, again, they were not specific which portion of the rule they are 
referring to. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for initial 
observation care provided on April 28, 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.