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

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on September 2, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that this service was necessary and is supported in 
the medical records. The Plan denied your request. The Plan says this service was billed with an inconsistent 
place of service code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a patient is registered inpatient or outpatient of a hospital, the correct place of service 
(POS) code is that of the appropriate inpatient or outpatient hospital POS code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this claim was submitted 
with POS code 21 (inpatient hospital). However, there is another claim for this enrollee for dates of service 
September 2, 2022, to September 4, 2022, which was submitted as an outpatient hospital claim (bill type 131). 
There is no documentation to show that the enrollee was registered inpatient on the date in question. Based on 
this information, we decided that Medicare rules for coverage of initial hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) provided on 
September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9375 billed for date of service September 1, 
2022, to September 14, 2022. 
 
You asked the Plan to pay for procedure code S9375. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9375 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9375 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9375 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9375 billed for date of service September 1, 2022, to September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left vacuum-assisted socket system (VASS). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical record documentation of specific volume loss requiring real-time 
volume management for the enrollee's left residual limb. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient requires a prosthesis for mobility and accomplishing daily activities. His current 
prosthetic socket is no longer fitting appropriately due to volume change of his residual limb. He requires a 
new prosthetic socket. The patient is noted to require dialysis. However, there is very limited clinical 
documentation regarding the objective volume change of his residual limb and if a vacuum assisted suspend 
system would allow for better fit and function. There is some medical literature indicating that vacuum assisted 
suspension systems may improve fit and function, but it is limited. Therefore, the vacuum assisted suspension 
system is not 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left vacuum-assisted socket system (VASS).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 28, 2022, to 
April 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like this claim to be 
reconsidered for payment based on medical necessity. The Plan denied your request. The Plan says that more 
details are needed to determine if these charges are eligible for coverage. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was admitted to the hospital with acute respiratory, pleural effusion, and 
pneumonia requiring mechanical ventilation support, antibiotics, thoracentesis, and sedation. Our reviewer also 
found that based on the complexity and severity of the presentation, it was expected that this patient would 
require hospital services that would likely cross 2 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 28, 2022, to April 3, 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided from June 24, 2022, 
to June 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim denied in error. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on August 4, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided additionally on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient therapy services provided from June 
24, 2022, to June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067), and take-home 
supply of methadone (G2078) provided on June 29, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services should be reprocessed for 
payment. The Plan denied your request. The Plan says the provider in this case is not eligible to receive 
payment from Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
(G2067), and take-home supply of methadone (G2078) provided on June 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has high probability of 
bleeding/stroke. The Plan denied your request. The Plan says the service is not 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an implantable cardiac monitor (ICM). In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ICM in this enrollees clinical 
management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ILR (CPT code 33285).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy (PBT). 
 
You asked the Plan to pre-approve PBT. 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 PBT is considered reasonable in instances where 
sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of 
added clinical benefit to the patient. 
 
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 PBT. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not meet the coverage 
criteria detailed in the LCD. There is insufficient prospective, long-term clinical data available to determine 
whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external 
beam radiation therapy, Intensity modulated radiation therapy (IMRT), or brachytherapy with regards to safety 
and efficacy. This is an observational study and is not for evidence development. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Therapy (PBT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee's 
condition does not allow Keytruda for continued use. 
 
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 physician reviewer 
found that the enrollee has a breast cancer tumor mutational burden of less than 10. There was initial concern 
for Taxol resistance, but the enrollee continued with Pembrolizumab /Abraxane. The enrollee switched to 
Halaven plus Keytruda, but unfortunately, the most recent scans showed progression. The request is for 
Keytruda monotherapy even as the enrollee completed adjuvant Keytruda and had clear biopsy-proven 
evidence of metastatic progression. Keytruda cannot be used as a single agent and previous progression on 
Keytruda. The documentation does not support that the requested drug is safe and effective and otherwise 
reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim reflex stimulation device (0266T and C1825). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the Barostim Neo device is considered unproven and 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Barostim reflex stimulation device (0266T and C1825).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS device. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have recurrent congestive heart failure (CHF). The clinical study on which Food 
and Drug Administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in enrollees in whom the CardioMEMS system was implanted, reflecting an enrollee 
population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies 
remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In 
addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in enrollee management.  As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultomiris infusions. 
 
You asked the Plan to pre-approve Ultomiris infusions. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Ultomiris infusions. Our reviewer says 
that the documentation does not support that Ultomiris infusions meet step therapy criteria. Our physician 
reviewer found the enrollee has acetylcholine receptor antibody positive generalized myasthenia gravis. The 
documentation does not support that the enrollee has tried and failed Vyvgart. The documentation does not 
support that Vyvgart would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ultomiris infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ultomiris infusions.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chemotherapy administration (96413), and durvalumab (J9173) 
provided on August 4, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the services were not medically necessary. 
 
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 pay for the outpatient services. Our reviewer says 
that the outpatient services are considered medically reasonable and necessary in this case. Our physician 
reviewer found durvalumab is indicated by the Food and Drug administration for treatment of the enrollee's 
condition. Therefore, the reviewer found that the services were medically necessary 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 the outpatient services have been met. Therefore, we decided that the Plan has 
to pay for the chemotherapy administration (96413), and durvalumab (J9173) provided on August 4, 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.
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 needs physical therapy. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested IRF services 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 that clinical documentation shows that the enrollee has functional impairments and chronic comorbidities with an IRF compliant diagnosis however evaluating therapists recommend continued 
therapy in the home setting on an intermittent basis. Thus, the enrollee would not be expected to require 
intensive therapy in an IRF 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized, 
and they are ready for discharge. You say the enrollee would benefit from admission to an LTACH to regain a 
maximum/prior level of functioning and continue a multidisciplinary approach to care. The Plan denied your 
request. The Plan says the request for coverage for admission to an LTACH is being denied as not medically 
necessary. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this 
time and completion of treatment at the current facility is recommended. 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.