Persius/hicric huggingface dataset:
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 enrollee would greatly benefit from inpatient 
rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF 
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 while the enrollee may benefit from continued physical and occupational therapy, the 
enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a 
skilled nursing facility (SNF). Our physician reviewer also found that the enrollee may need custodial 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the supplies do not require authorization. The 
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies provided on January 31, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has severe COPD with oxygen 
dependence, Covid-I9 pneumonia requiring intubation and dyspnea with exertion and hypoxemic hypercapnic 
respiratory failure. BIPAP is not sufficient for treatment of chronic respiratory failure and chronic obstructive 
pulmonary disease. In addition, The Life 2000, is meant to be used for portability not as a stationary treatment. 
The Plan denied your request. The Plan says the ventilator fails to meet the definition of reasonable and 
necessary. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. There 
is no documentation of chronic CO2 retention on an ABG done as an outpatient while the enrollee is stable, so 
she does not qualify for ventilatory support during sleep, such as BiPAP. The Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. There is inadequate evidence that it is 
beneficial in the treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on May 5, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 43501 is not supported. Specifically, there is a more comprehensive code to describe 
the services provided. 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 the surgery services provided 
on May 5, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 20 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says that additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that 
enrollee still requires physical assistance with mobility and is not at baseline which the Plan also agrees with. 
Thus, 20 additional physical therapy sessions would be 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 20 physical therapy visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Their relatively high functional status and their reduced endurance in therapy 
do not support that this patient requires an intensive IRF therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Estra/Noreth Tablet (1-0.5mg) for the enrollee. 
 
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part 
B. 
 
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 Estra/Noreth Tablet (1-
0.5mg) for the enrollee.  
 Benefits for self-administered drugs under Medicare Part B 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee must have tried or be unable to tolerate the Plan's preferred drugs 
before Cimzia can be approved. 
 
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 rules also say that if a Medicare Advantage (MA) plan decides to adopt and apply step therapy to 
Part B drugs, the MA plan must disclose that Part B drugs may be subject to step therapy requirements in the 
plans Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted the EOC document. Without this information, it 
cannot be verified that the Plan has disclosed Part B drugs may be subject to step therapy requirements. 
Therefore, we decided that the Plan has to pre-approve Cimzia.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint, requested CPT 
code(s) 64635. 
 
You asked the Plan to pre-approve these services. You say that this treatment is medically necessary. The Plan 
denied your request. The Plan says insufficient medical records have been submitted to determine medical 
necessity and the service requested is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any item 
or service, the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at 
the file and Medicare rules. Based on this information, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage for this service have been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation to the SI joint, requested CPT code(s) 64635.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 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 June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted molecular pathology procedure (Hereditary 
Cancer Syndrome (HCS) Panel Testing, including Lynch Syndrome testing) (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that the attached pathology supports your decision 
to order genetic testing with myriad. The Plan denied your request. The Plan says the requested test is 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 genetic testing. 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 medical justification for any additional testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an unlisted molecular pathology procedure (Hereditary Cancer Syndrome (HCS) Panel 
Testing, including Lynch Syndrome testing) (81479).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 31, 2022. 
 
You asked the Plan to pay for the services provided. You say that the reports support separate services. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78830 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 the radiology services 
provided on March 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that no one is at home to care for the enrollee. The Plan 
denied your request. The Plan says criteria for admission to SNF have not been met. Skilled services can be 
provided on an intermittent outpatient basis, in a long-term care facility, or at the home with home health care 
services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.  
 
You asked the Plan to pre-approve facet joint injections for the enrollee. You say that this treatment is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this treatment.  
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 this service. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the standard definition of a successful cervical facet block is 80% pain relief for duration of the local 
anesthetic.  The records show the enrollee only achieved 15% pain relief, so the cervical facets are not the 
probable pain generators. Medicare coverage criteria are not 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 this service 
have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for 
the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 24, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U, 81291, and 
81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 24, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 
0032U, 0033U, 81291, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided on October 10, 2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E1390 is not supported in the medical record. Specifically, the 36 monthly payments 
were met as of July 2021. No further payment for oxygen equipment will be made during the 5-year RUL after 
rental payments are made for 36 months of continuous use. We find that Medicare rule for payment for code 
E1390 has not been met. If the provider determines that a billing error occurred. This means that payment cannot be made for this item. Based on this information, we decided that Medicare rules for coverage of the 
oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the 
oxygen concentrator provided on October 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee needs continued services to 
improve mobility deficits and back pain. The Plan denied your request. The Plan says that skilled treatment is 
not needed at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist. There has been instruction in a 
home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight physical therapy visits.