Persius/hicric huggingface dataset:
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 you believe the enrollee will benefit from IRF 
services and the enrollee cannot accomplish their needs in a lower level of care. The Plan denied your request. 
The Plan says the records do not show that the enrollee is able to take part in 3 hours of therapy 5 days per 
week as they need help to stand. The enrollee's rehabilitation needs are not complex, and they do not need to be 
seen by a rehabilitation doctor 3 times per week for evaluation of functional and medical goals and progress. 
The services the enrollee needs can be provided safely in other settings like a skilled nursing facility (SNF), 
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 the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. 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. 
 
Documentation does not support necessity for admission to an IRF. While the enrollee may benefit from 
continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely provided 
in a lower intensity and alternate setting such as in an SNF with similar outcome. 
 
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: 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 would benefit from and 
improve with LTACH services with an expected stay longer than 25 days. The Plan denied your request. The 
Plan says the enrollee does not qualify for LTACH level of care, and it is not medically necessary for the 
enrollee at this time. The enrollee could safely receive the services they need in a lower level of care like a 
skilled nursing facility. 
 
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 more stable and improving and should only require 
short-term additional acute care services that can be safely administered at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. 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 at 
this time 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 the 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 your physician says you meet the criteria 
for LTACH admission. The Plan denied your request. The Plan says the records do not show that it is safe for 
the enrollee to leave the hospital. Additionally, the records do not indicate that condition will require an 
average of a 25 day stay in the LTACH. When the enrollee is ready to leave the hospital, they can safely 
receive this care in another setting like a skilled nursing facility. 
 
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 in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH for example, multiple and prolonged intravenous therapies, 
monitoring of significantly medically active conditions requiring clinical assessment 6 or more times a day, 
multiple and frequent intervention of at least 6 or more times a day, like ventilator management, cardiac 
monitoring, complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech 
equipment like cardiac monitors, on-site dialysis, or surgical suites.   
 
The enrollee does not require services at the LTACH that are not available at the acute care hospital or the 
skilled nursing facility. The requested treatments are not medically necessary at the LTACH level of care. The 
enrollee has improved medically and can receive further care at the current acute care hospital or a lower level 
of care when deemed appropriate. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed for date of service 
May 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim was billed in accordance with the 
enrollee's plan policy. The Plan denied your request. The Plan says the documentation does not support the 
billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the electrical stimulator supplies billed for date of service May 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for watchman procedure (33340). 
 
You asked the Plan to pre-approve the watchman procedure. You say that you have atrial fibrillation and need 
this watchman procedure to close the left appendage of your heart to keep you from having a life-threatening 
stroke. The Plan denied your request. The Plan says the records do not show that the enrollee meets the 
Medicare criteria for approval. 
 
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 watchman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of atrial fibrillation and has failed cardioversion and 
ablation treatments and is taking and tolerating Eliquis but wishes to avoid having to pay for and take this 
medication long-term. The provided records include clinical history information that indicates they have a 
CHA2DS2-VASc score of 3. Medicare guidelines state that the Watchman procedure is a second-line treatment 
to oral anticoagulation and requires that they must have a CHA2DS2-VASc score of at least 3 or more. Also 
required is that a second non-interventionalist doctor has discussed the positives and negatives of 
anticoagulation therapy compared to the procedure and still decided to undergo the procedure. However, as 
there was no found documentation of this second non-interventionalist doctor conversation or any evidence of 
the enrollee being not a candidate for long-term oral anticoagulation therapy, this enrollee does not meet the 
Medicare criteria, and therefore, also not meeting criteria for inpatient admission associated with the procedure. 
 
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 watchman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient admission for watchman procedure (33340).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose genetic testing provided on March 8, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is medically reasonable 
and necessary for the indications established in the applicable LCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested testing was not medically reasonable and necessary. Our physician reviewer found that there is no 
documentation from the provider documenting the drugs being considered for use, and no documentation to 
how the results will impact treatment. The requested testing was not medically reasonable or necessary 
according to the coverage criteria in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneDose genetic testing provided on March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service March 27, 2021. 
 
You asked the Plan to pay for hospital discharge management. You say that this level of service is supported in 
the documentation provided. The Plan denied your request. The Plan says this service is not supported in the 
medical record as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
care is not noted in the medical record. Without this information, a time-based code such as 99239 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of hospital discharge management have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) billed for date of service March 27, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve rituximab-PVVR for the enrollee. 
 
You asked the Plan to pre-approve rituximab-PVVR. You say that this is medically necessary. The Plan denied 
your request. The Plan says that that the requested medication has not been shown to be a safe and helpful 
treatment for your kidney condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 rituximab-PVVR. Our reviewer says 
that rituximab-PVVR is medically reasonable and necessary. Rituxumab has been shown to be beneficial in 
some patients with idiopathic nephrotic syundrome and Focal segmental glomerulosclerosis (FSGS) is one of 
these syndromes. It is not first line therapy, but this patient is failing tacrolimus (a calcineurin inhibitor). With 6 
grams of proteinuria and already with renal insufficiency, the patient at great risk for progression of renal 
disease. Rituximab is indicated as the patient has failed conventional therapy and Rituximab has been 
beneficial in some patients with idopathic nephrotic syndrome. Our physician reviewer found that the enrollee's 
condition meets criteria for coverage of rituximab-PVVR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rituximab-PVVR have been met. Therefore, we decided that the Plan has to pre-
approve rituximab-PVVR for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the heart CT provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for the heart CT. You say that the scan was part of a series of tests 
that were medically necessary. 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 $89.13 
copayment for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $89.13 copayment for the heart CT. This item/service falls within the other 
outpatient diagnostic tests - radiological diagnostic services, not including x-rays 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. The allowed amount for the CT scan is 
$89.13.  Since this amount is less than the $160 copayment per the EOC, you are only responsible for the lesser amount. 
Therefore, we decided that the Plan does not have to waive the copayment for the heart CT provided on April 
27, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
encephalopathy, decreased appetite and vomiting. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy (PT) or occupational therapy 
(OT), and an intensive rehabilitation therapy program. While the medical record supports a need for PT and/or 
OT, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code is not supported in the documentation. 
 
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 35355 is thromboendarterectomy, including patch graft, 
if performed; iliofemoral. We find that CPT code 35355 is not supported in the medical record. Specifically, 
there is a more comprehensive code to describe the services provided. 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 the surgery services provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing services provided on April 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test aids in selecting the right treatment options. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the gene panel was not billed with a single code as required. 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 the gene panel testing services provided on April 28, 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 with the enrollee's current condition and functional 
deficits they fully meet the Medicare guidelines for IRF admission. The Plan denied your request. The Plan 
says the records do not show that the enrollee needs to be seen by a rehabilitation doctor at least 3 times a 
week, that they need 3 hours per day of therapy at least 5 days per week, or that they need an intensive team 
approach for their care. The services the enrollee needs can be provided safely in other settings like 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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further services at a lower 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 IRF admission and services.