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

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission. The Plan denied your request. The Plan says the planned 
procedure is not listed on the Medicare Inpatient Only List. The Plan says that the procedure is currently 
approved as an ambulatory procedure and that there is no documentation to support the expectation that the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would clearly place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay.  Therefore, the record does not show that at the time of the request for an inpatient 
admission, the requesting physician reasonable expected that the enrollees necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
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. The Plan denied your request. The Plan says the enrollee does not 
need an intensive team for care. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for left sided weakness. Her medical problems are 
stable. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting IRF services so you can regain 
independence and being active as soon as possible. The Plan denied your request. The Plan says rules for IRF 
care 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not reasonable and 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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. He presented with back pain that radiates to the bilateral lower extremities, primarily down the 
posterior left leg down to the bottom of the feet. He has numbness in the feet, more pronounced on the left than 
the right. He had temporary relief with the epidural injections for 1 day. Current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
standard lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollees 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 26, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says there was 
no documentation of contact in the patient record. The listing of a referring provider on the claim or in the 
medical record does not satisfy the documentation criteria. 
 
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 psychotherapy services have not been met. Therefore, we decided that the Plan does not have to 
pay for psychotherapy services provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided to the enrollee on April 26, 2022. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature has determined that the requested service is not 
medically necessary for the enrollee's clinical condition. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that PrismRA detects an approximate chance of non-response to TNFi therapies. The enrollee had been 
on Humira, Remicade, Actemra, methotrexate, Arava, and Orencia, but has not been using any medication for 
her rheumatoid arthritis over the last 5-6 years and she is experiencing pain and stiffness in her joints. 
However, the provided documentation did not include a note stating the test was ordered and why it was 
ordered. There was no mention of which medication was to be tried next. The patient appears to have had 
benefit from Humira in the past which is a tumor necrosis factor inhibitor (TNFi), so it is not clear why the test 
was ordered. Therefore, the patient does not meet criteria for coverage.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA test provided to the enrollee on April 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for SNF care have not been met. 
 
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 that you have no identifiable skilled nursing service needs nor identifiable skilled 
therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not enough medical evidence that shows this procedure is 
helpful. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. RFA of the lateral 
sacral branches is considered experimental/investigational because of the wide variation in efficacy as 
published in the peer-reviewed literature. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with an anticancer regimen comprising 
Opdivo, irinotecan and dexamethasone. 
 
You asked the Plan to pre-approve Opdivo, irinotecan and dexamethasone. You say that the requested regimen 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules 
have not been met because the requested regimen is off-label and not medically accepted. 
 
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 Opdivo, irinotecan and dexamethasone. 
Our reviewer says that the requested regimen is not medically reasonable and necessary in this case. Our 
physician reviewer found that the requested use of Opdivo, irinotecan and dexamethasone is not FDA-approved 
for the enrollees diagnosis. Furthermore, the use is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-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 Opdivo, irinotecan and dexamethasone have not been met. Therefore, we 
decided that the Plan does not have to pre-approve treatment with an anticancer regimen comprising Opdivo, 
irinotecan and dexamethasone.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy and moderate sedation services (procedure 
code 31624, 31628, 99152) provided to the enrollee on August 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 31624: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar 
lavage 
 
CPT 31628: 
 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung 
biopsy(s), single lobe 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support the use of the denied codes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for bronchoscopy and moderate sedation services (procedure code 31624, 31628, 99152) provided 
to the enrollee on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR) device 
(33285). 
 
You asked the Plan to pre-approve an ILR device. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested service 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
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 an ILR device. Our reviewer says that 
the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that 
while the enrollee has a history of bradycardia and atrial fibrillation, the enrollee is asymptomatic. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of an implantable loop recorder (ILR) device (33285).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you have dialysis 3 times a week. The Plan 
denied your request. The Plan says your benefit only allows 60 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
 The file shows that 120 trips were requested. We looked at your request, the records in the case file, and the 
rules. Your plan contract shows that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchodilation responsiveness, spirometry (94060), 
plethysmography for determination of lung volumes (94726) and diffusing capacity (94729) provided on July 
1, 2021. 
 
You asked the Plan to pay for outpatient procedures. You say that you disagree with the denial of this claim. 
You also say per your coding department, claim is coded correctly. The Plan denied your request. The Plan 
says the services were billed for POS (21) with no modifier appended to any of the procedure codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 94060, 94726, 94729 is not supported in the medical record. Specifically, the 
professional component and the place of service was not properly billed on this claim. Based on this 
information, we decided that Medicare rules for coverage of outpatient procedures have not been met. 
Therefore, we decided that the Plan does not have to pay for bronchodilation responsiveness, spirometry 
(94060), plethysmography for determination of lung volumes (94726) and diffusing capacity (94729) provided 
on July 1, 2021.
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 inpatient rehabilitation services. 
The Plan denied your request. The Plan says rules for SNF care 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 pay for the chiropractic services provided from December 29, 2020, 
to January 27, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim 
denied correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that an office visit and x-rays were provided. These services are not manual manipulation of the 
spine. The file does not show that the services at issue were provided by a plan provider. Based on this 
information, we decided the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the chiropractic services provided from December 29, 2020, to January 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that after your surgery you are unable to care for 
yourself and your family cannot provide care. The Plan denied your request. The Plan says the records do not 
show the need for skilled nursing or medical management. 
 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 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 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 skilled nursing facility (SNF) care.