Persius/hicric huggingface dataset:
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 needing to go into inpatient rehabilitation. 
The Plan denied your request. The Plan says you do not meet Medicare criteria for admission to an inpatient 
rehabilitation facility. 
 
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 you have chronic impairment but are functioning at a level which does not 
require intensive rehabilitation. Additionally the chronicity of your impairment and your edema limit your 
capacity to respond to intensive rehabilitation. You do not have complex needs requiring physiatry input. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (eg, biopsy, 
aspiration, injection, localization device) (List separately in addition to code for primary procedure) provided to 
the enrollee on December 29, 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 laboratories should submit modifier LR (informational purposes only) to indicate "Round Trip" 
when using code P9604 (travel allowance, prorated trip charge). 
 
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 77002 is not supported in the medical record. Specifically, modifier LR is not meant to 
be used with CPT 77002. It is only meant for procedure code P9604, for travel allowance, prorated trip charge. 
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 fluoroscopic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) 
provided to the enrollee on December 29, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 21, 2022, through 
April 1, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that the provider did not submit the 
Request for Anticipated Payment (RAP) timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment by stating that the RAP was not 
submitted timely. However, as of January 1, 2022, providers are no longer submitting RAPs. Therefore, no 
RAP was required for this claim and the Plan is citing outdated rules that do not apply to the claim in question.  
Therefore, we decided that the Plan has to pay for the home health services provided from January 21, 2022, 
through April 1, 2022.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had appendicitis surgery and feel you need the 
therapy. 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 you are medically stable. At your current functional level you will not make 
significant functional recovery in a predicted period of time in an IRF especially at base line, you were not 
functional. 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 the Aurora spine ZIP fusion procedure. 
 
You asked the Plan to pre-approve the Aurora spine ZIP fusion procedure. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Aurora spine ZIP fusion procedure in the setting of lumbar spinal stenosis have not been 
demonstrated in the peer-reviewed literature. 
 
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 Aurora spine ZIP fusion procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested Aurora ZIP fusion procedure is experimental. More 
research is needed before coverage can be approved. 
 
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 Aurora spine ZIP fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Aurora spine ZIP fusion procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942) provided on 
March 30, 2022. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was billed 
without a required modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. The rules say that every chiropractic claim (those containing Current Procedural Terminology (CPT) 
codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004, is to include the AT modifier if active/corrective treatment is being performed 
 
We looked the file and Medicare rules. In this case, the claim was billed without modifier AT to indicate active 
treatment was taking place. As a result, the treatment provided will be considered non-covered maintenance 
care. Based on this information, we decided that Medicare rules for coverage of the chiropractic manipulative 
treatment have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatment (98942) provided on March 30, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the records do not show that the enrollee's rehabilitation needs are complex and 
that the enrollee needs to be seen by a rehabilitation doctor 3 times a week for evaluation of functional and 
medical goals and progress. The services the enrollee needs can be provided safely in other settings, for 
example, a skilled nursing facility, home with home health services or 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 based on the documentation provided, the health Plans denial should be upheld.  
The enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not 
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The 
enrollees care needs can be met at a lower level of care (ex. skilled nursing facility/ sub-acute rehabilitation). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybrevant (CPT code J9061). 
 
You asked the Plan to pre-approve the medication. You say that this course of treatment will offer the enrollee 
a much better chance to have response and duration of response compared to standard care, which is single 
agent chemotherapy. The Plan denied your request. The Plan says Rybrevant for the treatment of metastatic 
non-small cell lung cancer with unknown exon 20 mutational status is not FDA-approved and is not listed in 
drug information resources approved by Medicare. 
 
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 the medication. Our physician reviewer 
found the requested use of Rybrevant (CPT code J9061) is not FDA-approved for the enrollees diagnosis. The 
use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rybrevant (CPT code J9061).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection in the C7-T1 level (CPT 
code 62321). 
 You asked the Plan to pre-approve the epidural steroid injection. You say that the service is 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 epidural steroid injection. Our 
physician reviewer found the cervical magnetic resonance imaging (MRI) did not demonstrate any evidence of 
spinal canal or foraminal narrowing at any level. The review has determined that the medical records provided 
do not meet the requirements listed in the LCD for Medicare 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection in the C7-T1 level (CPT code 62321).
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 you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with septic shock, pneumonia, 
complicated by diabetic ketoacidosis (DKA), delirium and urinary retention.  
 The enrollee was started on antibiotics and mechanical ventilation support. Trach and percutaneous endoscopic 
gastrostomy were placed. Recent notes describe the enrollee with resolved DKA, improving encephalopathy, 
undergoing weaning trials, but still requiring vent support, antibiotics and tube feeds. The enrollee appears to 
be improving but still requires short-term additional acute care services that can safely be administered at the 
current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not available at the current facility. 
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with a urinary tract infection, 
sepsis, and encephalopathy requiring IV antibiotics and complicated by aspiration pneumonia, requiring 
intubation, rectal tube placement, and tube feeds. Hospice was recommended due to poor prognosis but refused 
by the family. Recent notes describe the enrollee as now having been successfully extubated but unable to have 
percutaneous endoscopic gastrostomy due to contractures.  
 The enrollee appears to be more stable and only requires short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not available at the current facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 genetic testing services. 
 
You asked the Plan to pre-approve F2 and F5 genetic testing services. You say that this service is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says under Medicare guidelines, 
this request is not medically necessary because these tests are described by 
Medicare as not clinically efficacious. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to 
be clinically efficacious; therefore, testing is not medically necessary. Based on this information, we decided 
that Medicare rules for coverage of F2 and F5 genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve F2 and F5 genetic testing services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
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 the medication. Our physician reviewer 
found the requested use of Retacrit is not FDA-approved for the enrollees diagnosis. The use of Retacrit is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Retacrit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the transportation of portable x-ray equipment (R0070) provided on 
March 10, 2022. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment. You say that you would like this 
claim reprocessed based on the medical records. The Plan denied your request. The Plan says that a decision 
was not rendered within the allotted timeframe. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the transportation of portable x-ray equipment (R0070) 
provided on March 10, 2022.  
 
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 physical therapy services (97110) provided on July 29, 
2022. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-
physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services (97110) provided on 
July 29, 2022.