Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve vascular services as requested (75822, 75820, 75825, 36011, 
36012, 37252, 37253, 76937, 99152, and 99153). 
 
You asked the Plan to pre-approve the vascular services. You say that the requested vascular services are 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested vascular services. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the vascular services. Our reviewer says 
that the enrollee meets criteria for the requested vascular services. Our physician reviewer found the enrollee is 
with complaints of recurrent superficial phlebitis, pain, discoloration, swelling, numbness, tingling, and bulging 
veins in her legs, worse on the left. The symptoms are affecting the enrollee's activities of daily living, 
including walking and standing. The plan included leg elevation, compression stockings, and exercises, as well 
as IV ultrasound to rule out May-Thurner syndrome or other stenosis of the iliac veins. On August 17, 2022, no 
evidence of deep vein thrombosis (DVT) was seen on ultrasound. Reflux was demonstrated to the 
saphenofemoral junction bilaterally. The CEAP classification is 4a in both the right and left legs. The V.C.S.S. 
right and left total scores were 8. 
 
The case file contains documentation of concern regarding May-Thurner syndrome or other stenosis of the iliac 
veins. The documentation supports that the coverage criteria for the requested procedures were met in this case. 
Intravascular ultrasound is regarded as a current venous imaging standard for establishing a diagnosis of May-
Thurner syndrome and can be a valuable adjunct for management of the 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 vascular services have been met. Therefore, we decided that the Plan has to 
pre-approve vascular services as requested (75822, 75820, 75825, 36011, 36012, 37252, 37253, 76937, 99152, 
and 99153).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (J9264). 
 
You asked the Plan to pre-approve Abraxane. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Taxol (paclitaxel) 
or Taxotere (docetaxel). 
 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 Abraxane. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed one of the preferred drugs, Taxol or Taxotere. The reviewer found that 
the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the 
plan's preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane (J9264).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure code 99283) 
provided to the enrollee on January 13, 2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the procedure code is inconsistent with the place of service. 
 
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 99283 is not supported in the medical record. Specifically, emergency department 
coding is only appropriate for an inpatient place of service. Place of service 22 is not appropriate, as it represents outpatient. Based on this information, we decided that Medicare rules for coverage of the visit have 
not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit 
(procedure code 99283) provided to the enrollee on January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM and supplies. You say that the requested supplies are 
medically necessary for the enrollee due to type 2 diabetes mellitus with hyperglycemia. The Plan denied your 
request. The Plan says the enrollee does not meet coverage criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Dexcom 
G6 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture services. 
 
You asked the Plan to pre-approve the acupuncture services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 acupuncture services 
have been met. Medical records were not provided to show that the enrollee meets the criteria for the services. 
Therefore, we decided that the Plan does not have to pre-approve the acupuncture services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will decline quickly without the 
rehabilitation and will be hospitalized due to denial of authorization. The Plan denied your request. The Plan 
says based on Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for a COVID-19 infection. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has 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 pre-approve the epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the injection. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not show that 
the enrollee meets all of the required criteria. Therefore, the procedure 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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the enrollee has had 4 injections already during the rolling 12-month period since 
October 21, 2021, which is the maximum allowed according to LCD 36920, regardless of the level and 
approach of the repeat injection. The review has determined that the enrollee does not meet LCD criteria for an 
epidural steroid injection and the epidural steroid injection 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the epidural steroid injection (62323).
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 enrollee is stable and clearly exceeds 
the Medicare established defining criteria for an appropriate long term acute care hospital admission. The Plan 
denied your request. The Plan says admission to LTACH was denied as not meeting criteria, is not medically 
necessary, and continued acute hospital stay was offered, until the enrollee could discharge to a lower level of 
care. 
 
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 inpatient hospital on September 19, 2022, for 
tuberculosis and pneumonia. There is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a higher level of care than the 
home setting or the skilled nursing facility (SNF) can provide due to his medical complexity and repeating 
hospitalizations without achieving medical and functional stability. The Plan denied your request. The Plan 
says the enrollee can safely receive the services you need in other settings, for example: a skilled nursing 
facility, home with home health services or perhaps home with outpatient therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 8-14 drug classes provided on 
November 11, 2021. 
 
You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary testing. 
The Plan denied your request. The Plan says the order form is not specific enough to justify the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory testing must be ordered by the treating 
physician.  
 
We looked at the file and Medicare rules. In this case, the order provided does not clearly indicate the number 
of drug classes required for testing. As such, payment for the billed code of 8-14 drug classes cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing of 8-
14 drug classes provided on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care and skilled nursing facility 
cannot provide a total interdisciplinary approach needed and will be served to educate the enrollee's family 
with compensatory feels well than useful return of function. The Plan denied your request. The Plan says that 
based on Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee has active comorbidities and would be expected to 
continue to require medical supervision on an inpatient basis. Evaluating therapists state the enrollee would 
require multi-disciplinary rehabilitation and an excellent rehabilitation prognosis thus criteria has been met and 
is 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and 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: 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 you feel that you require the higher level of 
rehabilitation care. The Plan denied your request. The Plan says criteria for IRF care are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to an acute hospital on September 9, 2022, with acute on 
chronic congestive heart failure, low sodium levels, and pneumonia with hypoxia. She also suffered acute kidney injury and requires ongoing dialysis. As of October 5, 2022, she tolerated only 30 minutes of therapy 
with multiple rest breaks.  
 
The enrollee is medically stable with metabolic encephalopathy and does not need physician supervision 3 
times a week in an IRF. She has no acute rehabilitation nursing needs. She will not tolerate the intensity of an 
IRF level of therapies. 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. She will not make a significant 
functional progress in a reasonable period of time in an IRF 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs help and is not okay to go home. 
The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may benefit from additional physical and/or occupational therapies, the documentation does not reveal 
that the enrollee's functional status requires this therapy at an IRF 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 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 the enrollee has a medical situation that is very 
difficult to manage in a skilled nursing facility due to understaffing and due to lack of attentive care that is 
needed on a daily basis. The Plan denied your request. The Plan says admission to IRF was denied as not 
meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing 
facility level of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that the enrollee requires or can tolerate this therapy 
on an intensive IRF level. 
 
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.