Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve occupational therapy services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve occupational therapy services. You say that this care is medically necessary. 
The Plan denied your request. The Plan says that there are multiple in-network providers the enrollee can 
choose from to receive this medical care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we requested the 2022 Evidence of Coverage to indicate that the 
Plan is restricting the enrollee to a network of providers. The Evidence of Coverage was not received. The Plan 
has failed to provide evidence that the enrollee is limited to a network of in-network providers that they may 
receive medical services from. Therefore, we decided that the Plan has to pre-approve occupational therapy 
services to be provided by an out-of-network (OON) provider.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (procedure code 97110) provided 
to the enrollee on September 9, 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 code is not appropriate for the services 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 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, there is a more appropriate 
code to use in the home setting.  
 
 
 
 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 physical therapy services (procedure code 97110) 
provided to the enrollee on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arterial puncture, withdrawal of blood for diagnosis (36600) 
pulmonary function test by gas (94727) provided November 12, 2021. 
 You asked the Plan to pay for the outpatient services. You say that please review the information to assist in the 
review and issue the additional $351.50 that is due.  The Plan denied your request. The Plan says CPT codes 
36600 and 94727 are not separately payable. 
 
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 claim was paid under the 
outpatient prospective payment system (OPPS). There is no separate ambulatory payment classification (APC) 
payment for CPT codes 36600 and 94727. 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 Arterial puncture, withdrawal of blood for diagnosis (36600) 
pulmonary function test by gas (94727) provided November 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (99499). 
 
You asked the Plan to pre-approve home health aide services. You say that due to a medical condition, the 
enrollee requires an attendant to be present at all times for his care and safety and should not be left alone. The 
Plan denied your request. The Plan says the requested home health aide services are not medically necessary 
and incorrectly coded as 99499. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
services meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2 and there is no documentation that the home health aide services are reasonable and necessary to the treatment of 
the enrollees illness or injury by the skilled professional staff as defined by Medicare guidelines. The enrollee 
is not receiving any skilled nursing or therapy services, thus home health aide services are not eligible for 
coverage by Medicare criteria. Private duty home health custodial services appear to be indicated 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services (99499).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited only to those drugs covered under your medical 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 Xeljanz for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 2, 
2021. 
 
You asked the Plan to pay for the CT scan. You say that the code should be linked to CPT code 49180. The 
Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 77012 may be eligible for payment when billed with 
code 49083. The claim does not show that the code at issue was billed with a modifier suitable for payment. 
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 the computed tomography (CT) scan provided on March 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence to support that the requested drug is safe and/or effective for biliary 
tract cancer. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab is not 
FDA approved for the treatment of biliary cancers. This enrollee does not have any markers that would indicate 
response to immunotherapy such as MSI-H, dMMR, or TMB high. Off-label use is not supported by major 
drug compendia or 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (Keytruda) for the enrollee.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
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 you 
do meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You have made progress at the inpatient rehabilitation facility (IRF). The documentation does not yet 
establish that you have reached a plateau in function, though this is likely to occur soon. A period of daily 
skilled services is reasonably required to establish a maintenance program and/or to prevent deterioration of 
your condition. You do require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
   
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 a semi-electric hospital bed (E0261) and dry pressure 
mattress (E0184) for the enrollee 
 
You asked the Plan to pre-approve a semi-electric hospital bed and dry pressure mattress. You say that a 
hospital bed will help with transfers bed mobility and avoidance of pressure ulcers. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for these items. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
The rules also say that a Group 1 mattress overlay or mattress can be covered if the Medicare criteria have been 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed and dry 
pressure mattress. Our reviewer says that a semi-electric hospital bed and dry pressure mattress are not 
medically reasonable and necessary. The patient is not completely immobile. The patient does not have limited 
mobility with the inability to make body position changes enough to alleviate pressure. The patient does not 
have a pressure ulcer on the trunk or pelvis. The documentation does not clearly reveal that patient's condition 
has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other 
ways is not feasible. The documentation does not support a need for frequent or an immediate change in body 
position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital 
bed is not medically necessary for this patient. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for a semi-electric hospital bed and dry pressure mattress. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed and dry pressure mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261) and dry 
pressure mattress (E0184) for the enrollee
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 17, 2021, to 
May 28, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says the RAP claim was not submitted within 5 days of the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at 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. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, May 17, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from May 17, 2021, to May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
November 6, 2021, through November 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was 
medically necessary. The Plan denied your request. The Plan says an inpatient hospital care was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the medical record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that your necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 6, 2021, through 
November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar injection services. 
 
You asked the Plan to pre-approve lumbar injection services. You say that the enrollee is in need of the 
requested injection services as her pain is debilitation and is affecting her quality of life. You say that the office 
notes and imaging reports support the need for the injection services. The Plan denied your request. The Plan 
says the records do not support a planned change in technical approach or a change in medication, nor do they 
support that the enrollee's pain or function was improved by at least 50% for three months after the last 
injection. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are covered when medically 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 lumbar injection services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the requested injection 
services would be repeat injections. The records provided do not demonstrate that the first injection provided at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from the baseline 
for at least three months. The requested additional blocks are not indicated or 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 lumbar injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar injection services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone/Apap tablets 
 
You asked the Plan to pre-approve Hydrocodone/Apap tablets. You say that this drug is medically necessary. 
The Plan denied your request. The Plan says this self-administered drug is not covered under the enrollee's Part 
B drug benefits. 
 
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 Hydrocodone/Apap tablets  
 
Benefits for Hydrocodone/Apap tablets 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 Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met as the 
clinical value and effectiveness of Keytruda in the absence of a preoperative pembrolizumab-containing 
regimen have not been demonstrated in the peer-reviewed literature. 
 
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 
requested use of Keytruda is not medically reasonable and necessary for the enrollee's condition. Our physician 
reviewer found the enrollee is a 76-year-old diagnosed with stage IIB triple negative breast cancer. In this case, 
the enrollee is post-surgery and the request is for Keytruda for adjuvant treatment. The requested use of 
Keytruda is not FDA-approved for the enrollees diagnosis as it is only approved as neoadjuvant therapy. 
 In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9721). 
 You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says payment for this service is not covered by the Plan as the enrollee is in 
a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Keytruda (J9721).