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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Health Plan. The Health 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 8, 2021, to 
December 15, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that they 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says the clinical evidence does not support assignment of code G93.41. 
 
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 G93.41-Metabolic encephalopathy. 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 inpatient hospital services at the DRG originally billed. 
Our physician reviewer found while the physician indicated a diagnosis of metabolic encephalopathy secondary 
to urinary retention, the clinical evidence did not support the diagnosis. The review has determined that the 
records do not support that the secondary diagnosis (G93.41-Metabolic encephalopathy) is appropriate for the 
hospital stay.  
 
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 on December 8, 2021, to December 15, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 348 units of code A0425 billed for date of service March 20, 
2022. 
 
You asked the Plan to pay for 348 units of code A0425. You say that this transportation was necessary as the 
patient had to lay flat following surgery. The Plan denied your request. The Plan says you billed units of code 
A0425 in excess of what is allowable on a single claim line. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with a MAI of 1, additional units of the 
code beyond the MUE are allowed if billed on a separate line with an appropriate modifier.  In this case, the 
code in dispute (A0425) has an MUE of 250 and has been assigned a MAI of 1.  This means that units billed in 
excess of 250 must be billed on a separate claim line and a modifier must be appended to this additional claim 
line.  In this case, you billed 348 units (nearly 100 more than the MUE allows per claim line), and you billed 
them all on one claim line.  You did not bill a secondary claim line with the excess units with a modifier as is required. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 348 units of code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for 348 units of code A0425 billed for date of service March 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the use of Keytruda is medically necessary. The 
Plan denied your request. The Plan says Keytruda is only for colon cancer that is microsatellite instability-high 
(MSI-H) or mismatch repair deficient (dMMR). The Plan says that this is also consistent with FDA-labeling. 
The Plan says that the provider has shown member is PD-L1+, but that they do not see any evidence of other 
testing. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found because the enrollee's microsatellite 
instability is unknown, the enrollee does not meet compendia or FDA label guidelines for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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. The Plan denied your request. The Plan says the IRF 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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain 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 acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that Medicare will not cover this 
service because they do not show that the patient was in hospice on this date. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, 
covers all hospice care from the effective date of election to the date of discharge or revocation. During the 
election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal 
illness until the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 21, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 88374. You say that this service was reported correctly. The Plan 
denied your request. The Plan says payment for code 88374 is bundled into payment for code 88377. 
 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, we have confirmed that code 88374 
is a column II code to column I code 88377. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88374 billed for date of service April 15, 2022.
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. The Plan denied your request. The Plan says the IRF 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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain 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 acute 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 say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or 
to require regular physician evaluation.  The enrollees care needs can be met 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on March 6, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says no proof of delivery was provided for the services 
rendered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that a proof of delivery was not provided for the items rendered on March 6, 2022. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor 
(CGM) provided on March 6, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
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 enrollee has not tried and failed the preferred step therapy drug(s) Infed (iron 
dextran) and Venofer (iron sucrose). The Plan states there is no indication the Plan's preferred drug(s) would 
likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Infed (iron dextran) and Venofer (iron sucrose) before they will approve 
the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 76641. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 30, 2022.
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 the enrollee is stable and ready to be 
discharged to an LTACH. You say that the enrollee will need wound care and pain management. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee is 
receiving the care they need in the current hospital 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 that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on February 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. CPT code 99215 denied per 
OCE Edit 062 for a code not recognized by Medicare for OPPS. Therefore, we decided that the Plan does not 
have to pay for the office visit (99215) provided on February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for this scan. 
 
The Plan follows Medicare rules. Medicare rules state that positron emission tomography (PET) scans may be 
covered for enrollees who meet diagnostic criteria for both Alzheimers Disease and Frontotemporal Dementia. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet criteria for the requested PET scan. Our physician reviewer found the record does not 
show that the enrollee meets criteria for both Alzheimer's Disease and Frontotemporal Dementia and the 
diagnosis remains uncertain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis. 
 
You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis. 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 follows Medicare rules. Medicare rules say that thrombophilia (or hypercoagulability) is the 
propensity to develop thrombosis due to either an acquired or inherited defect in the coagulation system. 
 
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 F2 gene analysis and F5 gene analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
family history of venous thromboembolism. The review has determined that the enrollee does not meet the 
coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 gene analysis and F5 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is substantial clinical evidence that 
supports this broad panel testing and the attached documents support its medical necessity. The Plan denied 
your request. The Plan says documentation does not support that the services rendered were medically 
necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows 
that the provider billed multiple procedure codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 
81301, 81317, 81401, 81194, and 81309 for multiple tests performed on the same specimen. This is incorrect 
coding per The Centers for Medicare & Medicaid Services (CMS); NCCI Coding Policy Manual for Medicare 
Services; Chapter X, which states if a laboratory procedure produces multiple results, only a single, appropriate 
code should be reported. This service was not supported by the medical records and procedure codes billed on 
this claim; therefore, it is not allowed. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 16, 2022.