Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (code 99284) provided on 
January 22, 2022. 
 
You asked the Plan to pay for the emergency department visit (code 99284). You say that code 99284 is 
supported by the medical records. The Plan denied your request. The Plan says that code 99284 at issue in this 
case is not supported by the medical records. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components. 
 Component 1: Must include a detailed history 
 Component 2: Requires a detailed examination  Component 3: Clearly delineated medical decision-making of a moderate complexity 
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 emergency department visit 
(code 99284). Our physician reviewer says that code 99284 at issue in this case is not supported by the medical 
records. Our reviewer found that the enrollee was a then 66-year-old female with a history of hypertension and 
status post right nephrectomy who presented to the emergency department on January 22, 2022 with 
complaints of low back pain radiating to the bilateral lower extremities for 1 day. The computed tomography of 
the lumbar spine demonstrated severe lumbar spondylosis. The enrollee was treated with analgesics and 
discharged home. The review has determined that code 99283 was more appropriate in this case. There was no 
decision making of high complexity. The presenting problems were not of high severity and did not pose an 
immediate significant threat to life and physiologic function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit (code 99284) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (code 99284) provided on 
January 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip joint replacement surgery to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve OON hip joint replacement surgery. You say that the requested provider is 
the one that recommended this surgery. The Plan denied your request. The Plan says this service is available 
from in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
hip joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 was admitted to the acute care hospital with a urinary tract infection, 
sepsis, acute respiratory failure, newly diagnosed colon cancer status post hemicolectomy. Recent notes 
describe the enrollee as now tolerating the trach collar with CPAP overnight, but still requiring ongoing total 
parenteral nutrition, intravenous antibiotics and dialysis, but without plans for additional surgery. The enrollee 
appears to be more stable and improving and should only require short-term additional acute care hospital 
services that can safely be provided at the current facility until more stable and appropriate for a lower level of 
care.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH 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 you would like admission to an IRF. The Plan denied 
your request. The Plan says you do not meet the 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 was hospitalized on September 3, 2022, for hypoxia and sacral wound 
infection with osteomyelitis complicated with cholecystitis status post percutaneous cholecystostomy 
placement and pulseless electrical activity arrest on September 14, 2022, requiring intubation. The enrollee is 
not currently on antibiotics nor continuous infusions and is tolerating tube feeding via percutaneous endoscopic 
gastrostomy tube and has not required prolonged mechanical ventilation. The enrollee is receiving appropriate 
care at the present setting. The enrollee does not require services at the LTACH that are not available at the 
health care setting where they are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcatheter aortic valve replacement (TAVR/TAVI) with 
prosthetic valve; percutaneous femoral artery approach (CPT code 33361) provided on June 9, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be processed. The Plan denied your 
request. The Plan says the clinical trial number was not billed on the claim. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. A review of our claims system 
shows Clinical Trial number was not billed on the claim. The denial for Clinical Trial number per the 2150 
Review for Coverage with Evidence Development (CED) Review is required criteria defined by the 
appropriate National Coverage Determination or a Reimbursement policy. Therefore, we find the Medicare 
rules for payment as not been met. Therefore, we decided that the Plan does not have to pay for transcatheter 
aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (CPT 
code 33361) provided on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says based on Medicare guidelines the long term acute care hospital 
services you are requesting do not meet the requirements for approval. 
 
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 was admitted to the acute care hospital with a fall, acute quadriplegia, 
epidural hematoma following recent cervical laminectomy and fusion procedure. This was complicated further 
by acute respiratory failure requiring intubation, mechanical ventilation support, surgery, tract and 
percutaneous endoscopic gastrostomy placement. The enrollee appears to be more stable and improving and 
should only require short-term additional acute care services that can safely be provided at the current facility 
until it is clearer if they are able to wean in the current location in a reasonable time frame.  
 The enrollee does not require services at the LTACH that are not available at the health care setting where they 
are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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 this service. Our reviewer says that this 
service is not medically necessary for the enrollee. Our physician reviewer found that the enrollee has diabetes 
and has unintended weight loss as well as nausea, vomiting, constipation, and mild anemia. A gastrointestinal 
consult with a planned endoscopy and colonoscopy is pending. Absent the gastrointestinal workup, the CT of 
the abdomen and pelvis is not yet indicated pending the results of those tests which are likely to be more 
beneficial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis with contrast (74177).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio 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 this request does not meet the plan's 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of a trial of Stelara before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug. There is no documentation provided indicating that the plans required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that your provider requested this service 
to make sure the nodules are remaining in place and will not cause any issues with your health. You also say 
that your provider wants to make sure you are healthy. The Plan denied your request. The Plan says you do not 
have a 20 packs per year smoking history. The Plan also says that you quit smoking more than 40 years ago. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 We reviewed the file and the Medicare rules. We find that you are not a current smoker or former smoker who 
quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
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 would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says LTACH is not 
medically necessary. The services the enrollee need could be provided in another setting, such as acute 
rehabilitation facility, SNF, outpatient setting or home care with home health. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve the physical therapy services 
 
You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says that 
this service is available by a provider in your network. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must ensure that services are 
provided in a culturally competent manner to all enrollees.  
 
The Plan does not have any providers that meet your language needs and are not able to offer the services in a 
culturally competent manner.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have been met. Therefore, we decided that the Plan has to pre-approve 
physical therapy services.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you have chronic obstructive 
pulmonary disease (COPD) and heart failure with a reduced ejection fraction (HFrEF), with chronic 
hypercarbic respiratory failure. You may benefit from bilevel positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) during sleep as an outpatient. But Medicare does not cover a home 
ventilator when used as BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. 
The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the 
enrollee's needs can be met at an alternate level of care setting like at 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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current functional mobility level, the enrollee does not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The enrollee needs physical therapy and occupational therapy in an alternate setting. 
 
The documentation does not support necessity for admission to an IRF due to lack of medical complexity and 
nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be provided in a lower intensity and alternate setting such as in a SNF. 
 
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 IRF admission and services.