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

 
We decided that the Plan does not have to pre-approve Feraheme (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that this medication will help with the enrollee's 
restless leg syndrome. The Plan denied your request. The Plan says this medication is not necessary. 
 
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 the medication. Our physician reviewer 
found the review has determined that the requested use of Feraheme is not FDA-approved for the enrollees 
diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS)-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 
the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme 
(CPT code Q0138).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Opioid Treatment Program (OTP) services provided on 
September 5, 2022. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says individual 
provider cannot bill for OTP services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities. 
 
We looked at the file and Medicare rules. The OTP services in question were not provided by a hospital, CAH, 
or Free-Standing Opioid Treatment Program facility, and therefore are not payable. Based on this information, 
we decided that Medicare rules for coverage of the OTP services have not been met. Therefore, we decided that 
the Plan does not have to pay for the Opioid Treatment Program (OTP) services provided on September 5, 
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 you require more intensive physical therapy than a 
skilled nursing home can provide. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for 3 units of calibrator solution (A4256) provided from May 16, 2022, to 
August 3, 2022. 
 
You asked the Plan to pay for 3 units of calibrator solution. You say that the documentation to support these 
items has been submitted. The Plan denied your request. The Plan says that this is not supported in the records. 
 
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. The Plan states that this was denied because the records do not support the items 
billed, and the original denial indicates that the billed units are not supported. However, the records submitted 
on appeal include an order for these items, medical records, and a delivery ticket showing that 3 units of 
calibrator solution were delivered. The Plan has not provided sufficient information to show that these items 
are not supported as billed. Therefore, we decided that the Plan has to pay for 3 units of calibrator solution 
(A4256) provided from May 16, 2022, to August 3, 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: 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 the IRF has a great rehab and is the next step in the 
enrollee's recovery. The Plan denied your request. The Plan says authorization for admission to an IRF is 
denied as the enrollee does not require this type of care. 
 
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's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: 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 meets criteria for an LTACH 
admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manipulation under anesthesia, shoulder joint, including 
application of fixation apparatus (23700). 
 
You asked the Plan to pre-approve manipulation under anesthesia. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says there were no notes sent to the Plan showing 
why the enrollee needs this procedure. The Plan needs to have notes that show that you have the health 
problems the rules require. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
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. The records show the Plan requested clinical and exam notes 
showing why the enrollee needs the requested manipulation. The records also show there is no information 
regarding the previously performed procedure. Records or information were not received. Based on this 
information, we decided that there is insufficient information in the record to determine if Medicare rules for 
coverage of manipulation under anesthesia have been met. Therefore, we decided that the Plan does not have to 
pre-approve manipulation under anesthesia, shoulder joint, including application of fixation apparatus (23700).
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 the enrollee is medically stable to be 
transferred to an LTACH level of care. You say that the enrollee requires extensive wound care management, 
renal management and needs continued acute care to prevent readmission to a short-term acute care hospital. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee's needs can be met at the current hospital setting. 
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on July 7, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the medically necessary service was provided to 
the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not 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 the home ventilator. Our physician 
reviewer found this enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) and backup rate during sleep. It appears this has not been tried and there is 
no evidence it has failed as an outpatient. There is no evidence that the enrollee was compliant with home 
BiPAP previously prescribed. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the device is medically necessary for the enrollee 
due to her advanced COPD associated with chronic hypercarbic respiratory failure. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 
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 ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with repeated 
hospitalizations for acute on chronic hypercarbic respiratory failure. The enrollee would likely benefit from 
BiPAP with AVAPS during sleep. There is no evidence that this treatment has been tried and failed as an 
outpatient. Medicare does not cover a home ventilator at settings that can be provided with BiPAP. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 28, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a High Efficiency Particulate Air (HEPA) air purifier. 
 
You asked the Plan to pre-approve a HEPA air purifier. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested 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 High Efficiency Particulate Air (HEPA) air purifier.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on August 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that services are not 
payable to a provider that is not Medicare certified. 
 
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. The Plan argues that the rendering provider is not Medicare certified. However, 
the Plan has not provided documentation supporting this claim. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on 
August 24, 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: 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. The Plan denied your request. The Plan says the enrollee does not 
have a medical complexity or have medical conditions so complex for the need of frequent monitoring by a 
physician on an inpatient basis in an acute inpatient rehabilitation facility. 
 
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 is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation.  The enrollees care needs can be safely met 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower 
extremity. 
 
You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
enrollee does not meet the criteria for this MRI. Our physician reviewer found there is no clinical rationale for 
the requested MRI of the hip. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the records provided support the 
need for the requested implantable loop recorder. The Plan denied your request. The Plan says the enrollee has 
not had recent syncope and has no history of a prior stroke. 
 
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 implantable loop recorder. Our 
reviewer says that an implantable loop recorder is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has had documented atrial fibrillation. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an implantable loop recorder. There is insufficient documentation to support the medical 
necessity for insertion of an implantable loop recorder in this patients 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.