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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an IRF stay. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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. 
 
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 an IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Part B step therapy criteria for the requested drug. 
 
 
 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 Aranesp. Our reviewer says that the 
enrollee does not meet the coverage criteria for Aranesp. Our physician reviewer found the enrollee is noted to 
have anemia, in the setting of chronic kidney disease. While it is reported that the enrollee previously received 
intravenous iron, there is no evidence that the enrollee is currently taking iron or what their current iron study 
bloodwork is. Our reviewer found that the nephrologist appears to be new for this enrollee, and while multiple 
old complete blood counts (CBCs) are noted, prior or current iron studies are not identified for review. Our 
physician reviewer also found that as such, the treatment criteria for Aranesp have not been shown to be 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the physician provided 
medically necessary services in good faith. The Plan denied your request. The Plan says there is inadequate 
documentation provided to support the medical necessity for repeat professional visits at a frequency which 
exceeds Medicare guidelines.  
The Plan follows Medicare rules. Medicare rules say that frequent visits by the physician in a nursing home 
setting would then be unnecessary, particularly if the patient is medically stable. 
 
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 evaluation and management service. Our 
reviewer says that the evaluation and management service was not medically necessary. Our physician 
reviewer found the provided documentation does not explain why the enrollee needed to be seen on the date of 
service in this case. The reviewer found that the documentation does not indicate there was evidence of a new 
complaint, injury, or illness. Therefore, the reviewer found that the evaluation and management service was 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 evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on October 
10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an 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 you do not meet all the requirements for admission to an IRF. 
 
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 your nursing, medical, and rehabilitation needs does not 
require an IRF stay. You were admitted for abdominal pain, pneumonia, anemia, and acute kidney injury. Your 
medical problems are stable, and there are no complex nursing or rehabilitation needs.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical therapy   
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure codes 99223 and 99233) provided to 
the enrollee from May 3, 2022 to May 8, 2022. 
 
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 documents don't support this level of care. 
 
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 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 initial history was not 
comprehensive. The interval histories were not detailed.  None of the medical-decision making was highly 
complex. While the enrollee appeared to have mild/moderate withdrawal, there is no evidence of 
moderate/severe withdrawal. There is no evidence of subsequent complications or new issues. Therefore, the 
billing of CPT 99223 and CPT 99233 x 5 is not supported. 
 
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 hospital care (procedure codes 99223 and 99233) provided to the enrollee from May 3, 2022 to 
May 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving and more stable with current treatment and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until more appropriate for a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that numerous trial and studies support the use of intensity-modulated radiation therapy 
(IMRT) in this situation. 
 
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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that based upon the provided records it is plausible that the proton plan would provided a clinically 
meaningful benefit as the intensity modulated radiation therapy (IMRT) plan did not achieve accepted 
dosimetric constraints for the oral cavity. The tonsillar target volume appears quite large, and it is plausible that 
proton therapy would yield an acceptable oral cavity dose exposure while IMRT could not. As proton therapy 
is an accepted standard when non-proton plans are inadequate based on standard dose constraints, the treatment 
would be provided according to generally accepted medical practice standards." 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve proton beam radiation therapy (PBRT).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you provider services on-site at the enrollee's 
community/home and home heath cannot provide the same level of service. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan and the enrollee can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascular stents (37228, 37229, 37231). 
 
You asked the Plan to pre-approve the revascular stents. You say that the records provided support the need for 
the requested treatment. 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 the revascular stents. Our reviewer says 
that revascular stents are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not meet coverage criteria and does not support the medical necessity 
of the treatments in question.  It is documented that the enrollee has right gluteal pain limiting his walking 
distance that has been unchanged for more than a year.  In that time the enrollee has undergone isolated tibial 
atherectomy and angioplasty of the right posterior tibial artery.  It is unclear how the enrollee responded to this 
treatment and his evaluation is not accompanied by a standard ankle-brachial index (ABI).  The most recent 
Quantaflow study provided demonstrates an improvement from his post intervention Quantaflow study.  It is 
unclear why a standard ABI is not provided.  There is no documentation suggesting symptoms consistent with limb threat. 
 
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 revascular stents have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascular stents (37228, 37229, 37231).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure code 99285) 
provided to the enrollee on August 4, 2022. 
 
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 documents do not support this level of care. 
 
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." 
 
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 in order to bill CPT 99285 a 
comprehensive history, comprehensive examination and complex medical decision making must occur/be 
documented. The history of present illness is limited. The medical decision making was not complex. The 
enrollees subacute complaint was not of high severity and did not pose an immediate risk to life or 
function. As such, the billing of CPT 99285 is not supported. 
 
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 an emergency department visit (procedure code 99285) provided to the enrollee on August 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist office visit 
provided on September 21, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should have never 
been scheduled for the specialist office visit because they could not schedule your procedure within the year. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for a specialist office visit.  
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
specialist office visit for in-network Medicare-covered services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network specialist office visit provided on September 21, 2022.