Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing in the home setting for monthly catheter 
changing. 
 
You asked the Plan to pre-approve skilled nursing in the home setting for monthly catheter changing. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing in the home setting for 
monthly catheter changing. Our reviewer says that the services are not medically reasonable and necessary. Our 
physician reviewer found Changing the suprapubic catheter does meet Medicare criteria for a skilled nursing 
service. However, based on the medical records provided there is inadequate support that the patient is 
homebound. Provided records document the enrollee is independent with transfers and can ambulate 50 feet, 
manage steps and curbs with supervision or touching assistance and does not require a wheelchair but uses a 
one-handed device such as a cane. The enrollee is reported to be alert and oriented with no memory deficits. 
Records do not clearly show that the enrollee is homebound and cannot go to a medical facility for the catheter 
changes. Therefore, the enrollee does not meet criteria for the requested 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 skilled nursing in the home setting for monthly catheter changing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing in the home setting for 
monthly catheter changing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88361 billed for 
date of service April 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the testing must be separately billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88361. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, 88360, and 88361 billed for date of service April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 06, 2021, 
through April 08, 2021, and billed with diagnosis code I50.23. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis I50.23 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of I50.23. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23 (Acute on chronic 
systolic (congestive) heart failure). 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis of I50.23 (Acute on chronic systolic (congestive) heart failure). Our physician reviewer 
found the history and physical noted that the member had shortness of breath at baseline from chronic 
obstructive pulmonary disease and reported no worsening with no edema. The member had no jugular vein 
distention, lungs were clear, and was maintained on his home diuretic. The member was clear to auscultation 
with no shortness of breath and no wheezing. Per review, the medical record found no evidence of clinical 
symptoms or findings on physical exam consistent with a diagnosis of acute chronic heart failure.  In addition, 
the chest x-ray showed no acute pulmonary opacity or pulmonary edema. With that being said, the 
documentation does not support I50.23 as a secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed.  
 
Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on April 06, 
2021, through April 08, 2021, and billed with diagnosis code I50.23.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Gamunex-C. 
 
You asked the Plan to pre-approve these services. You say that you would like a tier exception due to high 
medication cost. The Plan denied your request. The Plan says the drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that a Part B-covered drug is not eligible for a Part D 
tier exception. 
 
We looked at the file and Medicare rules. The requested drug is covered under Part B and is not eligible for a 
Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for 
Gamunex-C.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tracheostomy shower protector (A7523). 
 
You asked the Plan to pre-approve a tracheostomy shower protector. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tracheostomy shower protector (A7523).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON physical therapy services. You say that you are in terrible physical 
condition and are unable to leave the house without the help of others. You say that you were unable to find a 
network therapist who makes home visits and who is able to provide the desired level of service on time close 
to your home. The Plan denied your request. The Plan says there are network providers who are able to provide 
the care needed. 
 
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 at-home physical therapy services at issue in this appeal. We found no exception 
that would require the Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the medical records provided support the need for 
the drug in dispute. The Plan denied your request. The Plan says no support was found for the requested use of 
Keytruda. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Keytruda is not 
FDA-approved for the enrollee's diagnosis. The use of Keytruda in this circumstance 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 is stable and able to proceed 
to an LTACH level of care. You say that going to a lower level of care would result in a possible return to the 
emergency room due to not receiving six hours a day in nursing care. The Plan denied your request. The Plan 
says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has ongoing acute medical issues and still requires acute care 
services. The records do not indicate that the enrollee requires services that she is not currently receiving but 
that would be available at the LTACH facility. The enrollee continues to receive acute care services, and these 
have not been denied. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi electric hospital bed (E0260) safety enclosure 
frame/canopy for use with hospital bed (E0316) miscellaneous durable medical equipment (E1399). 
 
You asked the Plan to pre-approve the hospital bed. You say that the hospital bed is medically necessary due to 
the complex medical history. The Plan denied your request. The Plan says the records do not show that the 
enrollee has met the Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not require frequent or urgent changes and cannot reliably operate the bed 
controls. The purpose of the bed is to restrict movement at night. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve semi electric hospital bed (E0260) safety enclosure frame/canopy for use with hospital 
bed (E0316) miscellaneous durable medical equipment (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 7, 2022, 
to August 2, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the Plan has underpaid the claim, 
and you would like the balance to be issued to you. The Plan denied your request. The Plan says the inpatient 
services were not medically necessary. 
 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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the fairly non-acute presentation and negative workup, it was not 
expected that the enrollee would require hospital services that would likely cross 2 midnights to complete the 
workup and treatment. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from June 7, 2022, to August 2, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the home health services are medically 
necessary because of your past medical history. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment or falls or injuries which would necessitate skilled therapy visits. Medical records do not document 
that the enrollee is homebound. No medical notes from the enrollee's treating physician are provided 
documenting an order or need for skilled therapy 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not support that the 
required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual wellness visit (G0439) provided on July 29, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you relied on your doctor to tell you what 
you needed. You also say that this should be covered. The Plan denied your request. The Plan says that the 
benefit for this service has been exhausted. 
 
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. Specifically, the provided documentation does not support that the Plan has paid 
for this service within the calendar year. Therefore, we decided that the Plan has to pay for the annual wellness 
visit (G0439) provided on July 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service March 7, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that the denial of 
payment is incorrect. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88381. This 
means there is both a professional and technical component for the CPT code(s). In this case, an appropriate 
modifier to indicate the professional component has not been billed. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, 88360, and 88381 billed for date of service March 7, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not met criteria for 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum toxins (Botox, Dysport, Xeomin and 
Myobloc), will be considered medically reasonable and necessary when administered for treatment of FDA-
labeled indications and Off-label indications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have pelvic floor dysfunction and 
spastic pelvic floor syndrome. These conditions are not listed in the LCD's list of acceptable FDA-approved 
conditions or acceptable off-label conditions to help justify this request. Also, the provided records did not 
show that you have any other approved condition to support this request for Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.