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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. There are no needs that cannot be 
managed 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4154). 
 
You asked the Plan to pre-approve enteral formula. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the medical necessity for special enteral formulas 
(B4149, B4153, B4154, B4155, B4157, B4161, and B4162) must be justified in each beneficiary. If a special 
enteral nutrition formula is provided and if the medical record does not document why that item is medically 
necessary, it will be denied as not 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 enteral formula. Our reviewer says that 
you do not need this item. Our physician reviewer found there are no notes showing inability to absorb food or 
inability to swallow food. You are currently able to tolerate meals to some extent and do not need parenteral 
feedings.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral formula have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula (B4154).
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's goals are to get stronger and return 
home with sister. The Plan denied your request. The Plan says admission to an inpatient rehab is not medically 
necessary, the enrollee can receive care at a lower level of care such as at 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 the enrollee was diagnosed and treated for an acute on chronic decompensation of 
congestive heart failure and acute kidney injury. The enrollee has been treated medically and has stabilized. 
The issue is the medical necessity for admission to an inpatient rehabilitation facility is not met. 
 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan for the enrollee is medically 
necessary. The Plan denied your request. The Plan says that the medical records do not show that there is a 
reasonable indication for the CT scan of the abdomen and pelvis that is requested. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer found that the enrollee was 
previously evaluated for anemia and weight loss with labs, endoscopy and CT imaging. Recently, the enrollee 
has developed an increased lipase, including a level of 516 on November 4, 2022, and a level of 3267 on 
November 21, 2022.  While documentation interpreting these values is not provided, it is my opinion that the 
values themselves are significant cause to warrant the ordering of the CT imaging. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the abdomen and pelvis.  
 
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 pneumatic compression devices (E0652, E0667). 
 
You asked the Plan to pre-approve pneumatic compression device. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for PCDs 
have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD coded as E0652 have not been met. Specifically, the record does not show that the 
enrollee requires treatment of lymphedema extending onto the chest, trunk and/or abdomen. Because the base 
item E0652 is not covered, the related accessory coded as E0667 is also not covered. Therefore, we decided 
that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable scooter. 
 
You asked the Plan to pre-approve a foldable scooter. You say that you need this item. The Plan denied your 
request. The Plan says you do not need this item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a foldable scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure mattress. 
 
You asked the Plan to pre-approve the requested item. You say that the enrollee has chronic back pain and 
lower extremity pain. The Plan denied your request. The Plan says standard mattresses are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that pressure reducing support surfaces are only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that the enrollee is being treated for back pain. The 
records do not show that the enrollee has impaired nutritional statusy, incontinence, altered sensory perception, 
or compromised circulatory status. Furthermore, the requested item, billed with code E1399, did not include a 
narrative description of the item, the manufacturer, the product name/number, and information justifying the 
medical necessity for the item. Based on this information, we decided that Medicare rules for coverage of the 
requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a dry 
pressure mattress.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral lateral branch radiofrequency ablation (RFA) 
(64625) and moderate sedation (99152). 
 
You asked the Plan to pre-approve the RFA and sedation. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is experimental. 
 
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 RFA and sedation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this ablation procedure is considered investigational. Current evidence does not 
support this procedure as a reasonable treatment for the typical patient with chronic low back pain related SI 
joint dysfunction. 
 
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 RFA and sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral lateral branch radiofrequency ablation (RFA) (64625) and moderate 
sedation (99152).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission for application of 
Multiplane (20696). 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is 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 pre-approve acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no specific clinical rationale for the requested inpatient admission 
for the procedure. The requested procedure is not more complex than expected surgery and the enrollee does 
have any periprocedural or post procedure complication which would require inpatient care services. The 
record does not show that at the time of inpatient admission the admitting physician reasonably expects that the 
enrollee's necessary hospital care will 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 admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve acute inpatient hospital admission for application of Multiplane 
(20696).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on August 5, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was no longer enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
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 August 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on August 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service January 30, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service January 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Signatera genetic testing (81479). 
 
You asked the Plan to pre-approve Signatera testing. You say that this test is medically reasonable and 
necessary. The Plan denied your request. The Plan says this test is considered experimental and/or non-proven 
and therefore is not medically necessary. 
 
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 Signatera testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no direct evidence that the use of the test improves health outcomes, and 
indirect evidence is not sufficient to draw conclusions about clinical validity. The evidence is insufficient to 
determine that the technology results in an improvement in the net health outcome. The review has determined 
that the items/services at issue in this case are not medically reasonable or 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 Signatera testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Signatera genetic testing (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020. 
 
You asked the Plan to pay for the laboratory test. You say that this should be reprocessed based on the current 
federal guidelines for coronavirus testing and reimbursement. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020.
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 is not medically 
necessary. 
 
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 cognitive state inhibits his ability to participate in or benefit from 
intensive therapy. The enrollee's improvement in functional status over a 3-day period of hospital therapy 
indicates he does not require intensive therapy. The enrollee does not require frequent physiatry oversight. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the request 
does not meet Medicare guidelines for medical necessity because your medical condition requires further 
evaluation and treatment in the acute care hospital. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection, bevacizumab-bvzr, biosimilar, (Zirabev), 
10 mg. (Q5118). 
 
You asked the Plan to pre-approve the injection. You say that Zirabev is medically necessary for the enrollee's 
treatment for benign neoplasm of cranial nerves. 
 The Plan denied your request. The Plan says the use of this drug is not reasonable and necessary. No Medicare 
Compendia nor authoritative literature support was found for use in this enrollee's situation. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the proposed use of the medication is not for a FDA approved indication or a diagnosis 
supported within the Compendia (DRUGDEX Information System, the American Hospital Formulary Service 
Drug Information (AHFS-DI), Clinical Pharmacology, and Lexi-Drugs, NCCN). There is otherwise insufficient 
literature available to readily support the proposed safety and efficacy of this medication in this specific type of 
CNS tumor. As a result, this request would not be considered to be medically necessary or eligible 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg. (Q5118).