Persius/hicric huggingface dataset:
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 you do not meet criteria for IRF admission. 
 
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 you do 
not meet criteria for IRF admission. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You have multiple medical conditions, but these are currently being managed on an outpatient basis and there is a lack of documentation indicating that you require the intensity of physician 
oversight provided in the acute inpatient rehabilitation setting. You also do not require rehabilitation nursing 
for complex wound care, parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder 
management. Your medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided in an acute inpatient rehabilitation program. 
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
in an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over 
seven consecutive days. Currently, you are independent with bed mobility. You require minimal assistance 
with transfers and moderate assistance with daily activities, dressing and ambulation. You have had a decline in 
function with regards to mobility and performing your activities of daily living and would benefit from 
occupational and physical therapy, but you do not require the intensity of therapy services provided in the acute 
inpatient rehabilitation setting. Therefore, the acute inpatient rehabilitation admission 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with the out-of-network pain 
management specialist. 
 
You asked the Plan to pre-approve continued care with the out-of-network pain management specialist. You 
say that the requested continued care with the out-of-network pain management specialist is medically 
necessary. The Plan denied your request. The Plan says the requested continued care with the out-of-network 
pain management specialist is not medically necessary as there are in-network specialists available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued care with the out-of-network 
pain management specialist. Our reviewer says that the requested continued care with the out-of-network pain 
management specialist is not medically necessary as there are in-network specialists available. Our physician 
reviewer found there is no need for out of network referral for pain management treatment. This is a case of 
routine back pain. The enrollee can safely transfer to an in-network specialist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued care with the out-of-network pain management specialist have not 
been met. Therefore, we decided that the Plan does not have to pre-approve continued care with the out-of-
network pain management specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TMS treatment (CPT code 90868). 
 
You asked the Plan to pre-approve the TMS treatment. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the TMS treatment. Our physician 
reviewer found you do not meet the clinical criteria for the use of TMS therapy utilizing LCD L37086 as you 
had been given Zoloft which was stopped because you felt foggy. You have not undergone psychotherapy and 
there is no documentation of your patient health questionnaire (PHQ) 9 score. There is no documentation of 
you refusing electroconvulsive therapy (ECT). 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 TMS treatment have not 
been met. Therefore, we decided that the Plan does not have to pre-approve TMS treatment (CPT code 90868).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) billed for date of service December 13, 
2021. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were billed with an incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate DOS. Unless a specific exception is met, the appropriate DOS for a clinical laboratory test or the technical component of physician pathology is the date the specimen 
was collected.  
 
We find that the billed date of service of December 13, 2021, is not supported in the medical record. 
Specifically, the medical records provided show that the sample was taken on November 19, 2021. There is 
insufficient information to show that all of the criteria for any exception to this rule have been met. Based on 
this information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81479) billed for date of service December 13, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee was informed by a plan representative 
that if the diagnostic blocks were covered and paid that the radiofrequency ablation should be covered as well. 
The Plan denied your request. The Plan says the requested service 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 RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested RFA is considered an experimental or investigational procedure due to the wide variation 
in efficacy reported in the peer reviewed literature. Therefore, the reviewer found that the requested RFA is 
deemed 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64625).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium (75771). 
 
You asked the Plan to pre-approve a CT of the heart. You say that this service is medically necessary. 
 The Plan denied your request. The Plan says the criteria for the requested CT scan are not met, as the enrollee 
is at medium risk of developing coronary artery disease. 
 
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 a CT of the heart. Our reviewer says 
that the requested service does not meet the criteria for medical necessity in this case. Our physician reviewer 
found that current evidence showing that the use of coronary artery calcium (CAC) scores in clinical 
management of asymptomatic individuals is limited an inconclusive. Overall, there is insufficient support in the 
peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the 
heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this patient's medical condition. 
 
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 CT of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with quantitative evaluation of coronary 
calcium (75771).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says that the criteria for coverage for Tecentriq have not been met. 
 
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 Tecentriq. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with a high grade neuroendocrine large cell tumor. In this case, the requested use of Tecentriq is 
FDA-approved for the enrollees diagnosis. Large cell neuroendocrine carcinoma (LCNEC) is a rare 
pulmonary tumor, with features of both small cell lung cancer (SCLC) and non-small cell lung cancer 
(NSCLC). The treatment recommendations are based upon extrapolation from the approach to patients with 
SCLC, NSCLC, and the established literature, which is primarily retrospective in nature. This enrollee's tumor 
is acting more like a small cell lung cancer and carboplatin and etoposide were started and now atezolimab 
(Tecentriq) will be added. The requested drug is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have been met. Therefore, we decided that the Plan has to pre-
approve Tecentriq.  
 
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 cardiopulmonary resuscitation (CPR) services rendered 
on February 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 92950 is not supported. 
 
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 92950 is cardiopulmonary resuscitation (eg, in cardiac 
arrest). 
 
We find that CPT code 92950 is not supported in the medical record. Specifically, the records do not support 
the procedure was performed by the billing physician. 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 
pay for the cardiopulmonary resuscitation (CPR) services rendered on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 that the enrollee is a 77-year-old female with chronic obstructive pulmonary disease 
who was admitted to the acute care hospital with shortness of breath and multivessel coronary artery disease 
and underwent a coronary artery bypass graft with atrial appendage clip complicated by subcutaneous 
emphysema, COVID-19, and pneumonia requiring thoracotomy, chest tube, intubation, steroids, trach 
placement, and antibiotics. Recent notes describe the enrollee with leukocytosis, loose stool, and not fully alert. 
The enrollee appears to still be somewhat unstable but improving and should require only short-term additional 
acute care services that can safely be administered at the current facility until more stable and appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary at this time as the patient is not yet stable for 
transfer and as it would not be clinically advantageous. 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 long term acute care hospital (LTACH) services.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure, chronic obstructive pulmonary disease (COPD), and COVID 19 pneumonia. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dysport (abobotulinumtoxina) (J0586). 
 
You asked the Plan to pre-approve Dysport. You say that the requested injection is medically necessary. The 
Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
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 Dysport. Our reviewer says that the 
requested drug, Dysport, is not medically necessary. Our physician reviewer found the requested drug is not 
approved by the Food and Drug Administration for the enrollee's diagnosis. The reviewer also found that the 
use of Dysport for treatment of chronic migraines is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the 
requested drug is 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 Dysport have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Dysport (abobotulinumtoxina) (J0586).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the abdomen and pelvis 
(74177) provided on January 19, 2022. 
 
You asked the Plan to pay for the CT scan. You say that this service was medically necessary and was coded 
correctly. The Plan denied your request. The Plan says there is insufficient information to support the medical 
necessity of these services, including no order from the enrollee's primary care physician or attending physician 
requesting these services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. In addition, diagnostic tests which are not ordered by the physician who is 
treating the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CT scan have been met. 
Specifically, there are no medical records prior to services which would show this test was medically 
necessary, and there is no order for this service from the treating physician in the record. Therefore, we decided 
that the Plan does not have to pay for computed tomography (CT) of the abdomen and pelvis (74177) provided 
on January 19, 2022.
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 the documentation does not support the medical necessity due to lack of medical 
complexity and nursing needs, and current level of function for admission to an IRF. While you would benefit 
from physical therapy (PT) and occupational therapy (OT), your rehabilitation needs can be safely provided in 
an alternate and low intensity setting such as in a skilled nursing facility (SNF) or in-home with services. 
 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 you are appealing the denial of an IRF admission. 
The Plan denied your request. The Plan says IRF services are 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 that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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.