Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798, 87481, 87801, 87799, 87640, 
87653) provided on August 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says that they were unable to make a determination on this 
case in the required time frame. 
 
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, the Plan has provided no clear rationale with supporting citation 
and evidence to justify the denial of these services. Therefore, we decided that the Plan has to pay for 
laboratory services (87150, 87798, 87481, 87801, 87799, 87640, 87653) provided on August 24, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the Plan's 
denial for admission to an IRF. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is able to participate in intense therapy 
services for three hours per day/15 hours per week and is expected to make a measurable improvement. The 
Plan denied your request. The Plan says criteria for admission to the IRF have not been met. 
 
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. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living 
and personal care (99509). 
 
You asked the Plan to pre-approve the aide services. You say that you disagree with the denial. The enrollee 
needs help with personal care (like bathing, grooming, toileting, meal preparation, and/or cleaning). The Plan 
denied your request. The Plan says for Medicare to cover home health aide services, the enrollee must also be 
getting the services of a nurse or therapist in the home at the same time as the home health aide services 
provided by a Medicare certified provider. 
 
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 looked at the file and Medicare rules. The records show that the enrollee is needing help with personal care 
such as bathing, grooming, and meal preparation. Medicare and/or the Plan do not cover this care unless it is 
medically necessary for the enrollee to receive skilled nursing or therapy care. Based on this information, we 
decided that Medicare rules for coverage of the aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care 
(99509).
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 inpatient rehabilitation is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee would be better suited for 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 does not require the intensity of services provided at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (CGM). 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
provide a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has post-menopausal 
osteoporosis. She has not tried and failed the Plan's required drugs, an oral bisphosphonate and zoledronic acid. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Prolia 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
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 meets the criteria for an inpatient acute 
rehabilitation stay. The Plan denied your request. The Plan says the medical record shows that the enrollee's 
condition has not stabilized and will continue to require acute care management in the current hospital setting. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for necrotizing fasciitis and a below the knee amputation. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the medical records support a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 IRF admission and services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit coded as 99283, 87426 and 0223U 
provided July 7, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that you believe that the charges are appropriate for 
the level of acuity and intensity of the quality medical services provided and for the expertise required to 
provide these services. The Plan denied your request. The Plan says that Medicare does not cover services that 
are not performed by a Medicare certified provider. 
 
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. the Plan has not substantiated their reason to continue to deny. The provider has 
provided their Letter of Medicare Certification dated November 19, 2020. Therefore, we decided that the Plan 
has to pay for the emergency department visit coded as 99283, 87426 and 0223U provided July 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and electrocardiogram provided on June 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit and electrocardiogram provided on June 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections in both knees. 
 
You asked the Plan to pre-approve the Orthovisc injections. You say that the enrollee has tried physical 
therapy, but could no longer continue after the fifth visit due to pain and no relief of symptoms. You also say 
that the enrollee has tried anti-inflammatory Mobic 15mg one daily from March 8, 2022, to January 19, 2023, 
with no relief. The Plan denied your request. The Plan says the enrollee does not meet the conditions to 
approve this request. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Orthovisc injections. Our reviewer 
says that Orthovisc injections are not medically reasonable and necessary for the enrollee. Our physician 
reviewer found the enrollee has not undergone at least 3 months of conservative therapy. The review has 
determined that the requested use of Orthovisc is not FDA-approved for the enrollees diagnosis. Our reviewer 
also found that its use is not supported by one of the major drug compendia or by clinical research that appears 
in a Centers for Medicare and Medicaid Services (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 the Orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections in both knees.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for lower intestinal endoscopic procedures, endoscope 
introduced distal to duodenum (00813) anesthesia for patient of extreme age, younger than 1 year and older 
than 70 (99100) provided May 3, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that please review for payment. You believe 
these charges were inappropriately denied. The Plan denied your request. The Plan says that the Plan 
reimburses ASA codes to anesthesia providers only. 
 
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. the Plan has not substantiated their reason to continue to deny payment. The 
records show that the provider is a CRNA (Certified Registered Nurse Anesthetist). The Plan has not provided 
any documentation on how the CRNA is not a qualified anesthetist. Therefore, we decided that the Plan has to 
pay for the anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum 
(00813) anesthesia for patient of extreme age, younger than 1 year and older than 70 (99100) provided May 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electric stimulator supplies (A4595) provided on August 8, 
2022. 
 
You asked the Plan to pay for the supplies. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the items billed. 
 
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. An itemized proof of delivery was not provided. 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 electric stimulator supplies (A4595) provided on 
August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and appropriate. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nubeqa Tab 300mg. 
 
You asked the Plan to pre-approve prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Nubeqa is a self-administered drug. Based on this information, the 
requested medication does not fall under Part B coverage. 
 
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 Nubeqa Tab 300mg.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 intensive rehabilitation. A decline in function during home care 
therapy also indicates you are unlikely to respond to intensive therapy. 
 
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 pay for the inpatient psychiatric admission provided from April 26, 
2022, to July 15, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric admission. The Plan denied your request. The Plan says 
this request is not medically necessary because the records received show the enrollee's condition improved and 
they were no longer a threat to themself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 psychiatric admission. Our 
reviewer says that the enrollee did not meet the Medicare criteria for inpatient psychiatric care. Our physician 
reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates 
in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and 
without aggressive behaviors while not showing any acute threats of safety. Our reviewer also found that it did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than 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 the inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient psychiatric admission provided from April 26, 2022, to July 
15, 2022.