Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that in order to sustain a safe and sustainable 
discharge, LTACH is the best option for the enrollee's care. The Plan denied your request. The Plan says the 
requested LTACH services 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 is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the enrollee was 50% better after 
the last injection. The Plan denied your request. The Plan says criteria for a repeat ESI have not been met. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation of 50% pain relief for at least 3 months. 
Therefore, an epidural steroid injection is not indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service February 3, 
2021. 
 
You asked the Plan to pay for procedure code 99601. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service February 3, 2021.
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 an LTACH admission is medically 
necessary. 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 appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for transfer. It is not clear from the notes if this enrollee is able to wean at this time. 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 as the enrollee has abnormal findings on chest x-ray 
not fully clarified yet and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended before transfer.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that less extensive interventions are 
inadequate for the enrollee's condition. The Plan denied your request. The Plan says the device is experimental. 
 
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 requested services. Our physician 
reviewer found that a CardioMEMS pulmonary pressure sensor implantation to treat congestive heart failure 
has been requested. There remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the CardioMEMS 
system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve CT scan. You say that the CT scan is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not meet the Medicare criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has 
bilateral hand tremors and a history of atrial fibrillation. Given the risks and the presence of tremors, the 
request for a CT scan is medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomography (CT) scan.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the record shows that the enrollee does not meet Medicare guidelines 
for services in an inpatient rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the member has multiple active comorbidities and complications per clinical documentation and requires 
close medical monitoring. Our physician reviewer also found that the evaluating therapists states that the 
member would be able to tolerate and significantly benefit from intense therapy plus IRF criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 microprocessor foot. 
 
You asked the Plan to pre-approve the foot. You say that the foot is necessary. The Plan denied your request. 
The Plan says the records they have do not show why the requested computerized foot is needed. 
 
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 foot. Our physician reviewer found 
there is insufficient support that the K3 microprocessor foot at issue in this case meets Medicare's LCD: Lower 
Limb Prostheses (L33787) criteria for medically reasonable and necessary. Provided records do not document 
trial and failure of a new mechanical left foot. Provided records report that a cane or walker is expected to used 
even after provision of the requested device; this is not consistent with a K3 ambulatory level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the foot have not been met. Therefore, we decided that the Plan does not have to 
pre-approve K3 microprocessor foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs volume assured 
pressure support with targeted tidal volume. The Plan denied your request. The Plan says settings that could be 
delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 requested services. Our physician 
reviewer found that the provided records document chronic obstructive pulmonary disease, but the records are 
inadequate to support the diagnosis of chronic respiratory failure. The records do not include any arterial blood 
gas reports. Her oxygen saturation was reported as 93% with no mention of utilization of supplemental oxygen. 
There is no documentation that the ventilator at issue in this case meets Medicare criteria for medically 
necessary and reasonable for this enrollee. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve an IGRT. You say that due to mitigating factors, it was determined that 
image-guided superficial radiation therapy was medically necessary for this enrollee. The Plan denied your 
request. The Plan says the use of IGRT with superficial radiation therapy is considered 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 an IGRT. Our reviewer says that the 
IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
usually, IGRT is used when critical structures are abutting or in close proximity to the target that is being 
treated to high doses. This situation does not apply to this enrollee for which the target lesion can be seen on 
the skin to assist in daily set up. Our reviewer found that when treating skin cancers, there is generally not a 
need for IGRT unless deep structures are being treated. Our physician reviewer also found that using 
ultrasound on a daily basis is not unreasonable, but to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general), billing for daily simulations or 
IGRT would not be furnished in accordance with accepted standards of medical practice.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an image guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH has been determined to be 
the most appropriate level of care. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
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 appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility, until more appropriate 
for transfer to 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 at this time. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission is 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 the provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while you have a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation 
that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therefore, the reviewer found that the requested IRF admission is not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve carboplatin (J9045) and paclitaxel (J9267). 
 
You asked the Plan to pre-approve carboplatin and paclitaxel. You say that the enrollee has a highly aggressive 
disease. You also say that this is medically necessary. The Plan denied your request. The Plan says that the 
requested regimen is not medically necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 carboplatin and paclitaxel. Our 
reviewer says that a regimen of carboplatin and paclitaxol is medically necessary. Our physician reviewer 
found the requested regimen is supported in medical journals. The reviewer found that weekly PCb 
(carboplatin and paclitaxol) regimen was very active and tolerable as neoadjuvant treatment of the enrollee's 
diagnosis. The reviewer also found that this weekly PCb regimen should be considered a reasonable 
nonanthracycline-containing option in the neoadjuvant treatment of breast cancer. Therefore, the reviewer 
found that the requested regimen is medically reasonable and 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 carboplatin and paclitaxel have not been met. Therefore, we decided that the 
Plan has to pre-approve carboplatin (J9045) and paclitaxel (J9267).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has a contraindication to bisphosphates and 
continued bone loss. The Plan denied your request. The Plan says the enrollee has not tried and failed a 
zoledronic acid or has a history of osteoporosis-related fracture. 
 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 Prolia. Our physician reviewer found 
that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 
Therefore, the requested service cannot be 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.