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

 
We decided that the Plan has to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. The Plan denied your request. The Plan says that there is no 
documentation that the Plan's preferred medications have been tried/failed or there is a medical 
contraindication to trying them first. The Plan also says it appears that the enrollee is on Eyelea treatments, and 
the documents do not note a failure to this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare the Plan must disclose that Part B drugs may 
be subject to step therapy requirements in the Evidence of Coverage, and must be included in the Medical 
Benefits Chart under Medicare Part B prescription drugs". 
 
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's 2022 Evidence of Coverage does not include information 
disclosing the step therapy requirements. Therefore, we decided that the Plan has to pre-approve Vabysmo.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the data is used for heart failure 
management. The Plan denied your request. The Plan says the device has been determined to be of uncertain 
value. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. 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 power wheelchairs are covered when specific criteria 
are 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 a group 3 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found a group 3 wheelchair 
is medically necessary to address high risk skin care needs, intermittent catheterization, ventilator use or 
spasticity. Your condition does not require a group 3 wheelchair. 
 
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 group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair.
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 the admission is necessary. The Plan 
denied your request. The Plan says the requested LTACH admission and care are 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 provided documentation indicates the enrollee is receiving appropriate care at the 
present acute care hospital. The 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. Therefore, the reviewer 
found that the requested LTACH services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228) and technical support (93229). 
 
You asked the Plan to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor. You say that it was 
recommended to you to use continuous heart monitoring. You also say that the provider put in an order for this. 
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 a mobile cardiac outpatient telemetry 
(MCOT) monitor. Our reviewer says that the requested MCOT monitor is not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is no supportive evidence that standard, non-
MCOT, ambulatory electrocardiogram (ECG) monitoring would be inadequate. The reviewer found there is 
insufficient documentation to support the medical necessity for an MCOT monitor. Therefore, the reviewer 
found the requested MCOT monitor 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 a mobile cardiac outpatient telemetry (MCOT) monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228) and technical support (93229).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee can't walk or stay awake and is in 
desperate need to be cared for outside of his wife. The Plan denied your request. The Plan says based on 
Medicare guidelines the skilled nursing facility services you are requesting do not meet the requirements for 
approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have any parental medication, complex wound care or nutrition 
given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic or 
medical problems. Physical function is at or near the enrollee's baseline and can receive services at a lower 
level of care. The enrollee does not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve median nerve block injection services. 
 
You asked the Plan to pre-approve median nerve block injection services. You say that the records provided 
support that the requested injection services are medically necessary. The Plan denied your request. The Plan 
says given the enrollee has had symptomatology of carpal tunnel syndrome for almost 5 years, it is unclear why 
he has not been referred for possible surgical release of the median nerve. 
 
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 median nerve block injection services. 
Our reviewer says that median nerve block injection services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no role for nerve blocks in the treatment of carpal 
tunnel syndrome. The enrollee has not had a surgical consultation documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of median nerve block injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve median nerve block injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS heart failure system (CPT code(s): 
33289 and C2624). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence that shows use of the device is helpful, safe and 
improves the quality of life. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time the CardioMEMS system would not be considered medically appropriate 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 services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS heart failure system 
(CPT code(s): 33289 and C2624).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the medical 
documentation submitted for review indicates that the services requested can be appropriately provided in an 
alternative setting and that you require physical therapy only. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and can receive further rehabilitation services at a lower 
level of care. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you 
do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on 
February 4, 2022. 
 
You asked the Plan to pay for an emergency department visit. You say that this is supported in the records. The 
Plan denied your request. The Plan says the record supported code 99284 instead of 99285. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.   
The definition of 99284 is emergency department visit for the evaluation and management of a patient, which 
requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the 
physician, or other qualified health care professionals but do not pose an immediate significant threat to life or 
physiologic function.  
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the record does not show 
that the enrollees presenting problems were of high severity and posed an immediate significant threat to life 
or physiologic function. Based on this information, we decided that Medicare rules for coverage of an 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit (99285) provided on February 4, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for laboratory services. We decided that the Plan does not have to pay for 
drugs.  
 
You asked the Plan to pay for laboratory services (82948, 85052, 80053, 83735, 36415, 87340) and drugs 
(Q4081, J1644, J2270, J1642) provided from June 8, 2021, to June 9, 2021.. You say that this claim is payable 
as billed. The Plan says that this claim contains only packaged services. 
 
We decided that the Plan has to pay for laboratory services.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). Under the Outpatient 
Prospective Payment System (OPPS), packaged services are items and services that are considered to be an 
integral part of another service that is paid under the OPPS. Q4 services are assigned to laboratory codes that 
appear on the Clinical Laboratory Fee Schedule. When a Q4 service is not billed on the same claim as another 
separately payable service then their status indicator automatically changes to A and separate payment is 
made.  
 
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 states that the services billed are packaged, however, the codes billed 
for laboratory services (82948, 85052, 80053, 83735, 36415, 87340) have an OPPS status indicator of Q4 and 
were not billed with a separately payable service. The Plan has not provider any information to support the 
denial of these services. Therefore, we decided that the Plan has to pay for laboratory services.  
 
We also decided that the Plan does not have to pay for drugs. 
 
The Plan follows Medicare rules. Medicare rules say that unconditionally packaged services are services for 
which separate payment is never made because the payment for the service is always packaged into the 
payment for other services. Unconditionally packaged services are identified in the OPPS Addendum B with 
status indictor of N.  
 
The codes billed for drugs (Q4081, J1644, J2270, J1642) have an OPPS status indicator of N and are not 
separately payable. Therefore, we decided that the Plan does not have to pay for drugs. 
 
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 admission is necessary for the enrollee. The Plan 
denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission 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 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 pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that it is felt this is necessary to treat the enrollee's 
respiratory condition. The Plan denied your request. The Plan says an alternate device would meet the 
enrollee's needs. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not shown to be medically necessary. Our physician reviewer found the records 
provided document that the home ventilator is being requested for use in average volume assured pressure 
support (AVAPS) mode with auto-titration which could be provided by a bilevel positive airway pressure 
(BiPAP) device with back-up rate.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.