Persius/hicric huggingface dataset:
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 stable and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require transfer to an LTACH. 
 
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 all medically necessary care is being provided in the current acute care setting. 
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 Plan. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism purchased on October 27, 2022. 
 
You asked the Plan to pay for a seat lift mechanism. You say that the item was medically necessary. The Plan 
denied your request. The Plan says you obtained this item through a provider that is not enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism purchased on 
October 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. The Plan denied your request. The Plan says the services 
requested are not supported based on the medical records received, services needed may b safely provided in a 
skilled nursing 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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's records 
do not show that rehabilitation needs are complex and does not need an intensive team for care, services needed 
can be provided safely in other settings, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service October 13, 2022. 
 
You asked the Plan to pay for code 99204. You say that medical records were provided to support payment of 
this code. The Plan denied your request. The Plan says the medical records do not support code 99204 because 
the records don't show a moderate level of decision making or total time required for this code. 
 
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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 We asked our coder 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 code 99204. Our reviewer says that code 99204 is not 
supported in the medical records. Our reviewer found the enrollee was a then 72-year-old female with a history 
of senile dementia of the Alzheimer type and chronic obstructive pulmonary disease who was evaluated for 
dysphagia on October 13, 2022. In this case, the medical records submitted did not support moderate level of 
medical decision making or total time required of the code billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99204 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99204 billed for date of service October 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (coded 99285) provided on 
November 27, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says in order for a facility to receive reimbursement for a 
Medicare member, the facility must be enrolled to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. We looked at the file and the Medicare rules. The file shows that this facility is not a hospital and has no 
affiliation with a hospital. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit (coded 99285) provided on November 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
24, 2022. 
 You asked the Plan to pay for procedure code 99291. You say that the claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 99291 is one (1). The MAI value for this code is two (2). You billed two 
(2) units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99291 billed for date of service November 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service June 4, 2022. 
 
You asked the Plan to pay for procedure code 99306. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says the code used to report the services provided is not 
supported in the medical records. 
 
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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit. 
 
We asked our coder 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 procedure code 99306. Our reviewer says that the reported 
code is not supported in the medical records provided. Our reviewer found that although the documentation 
does support a comprehensive examination and medical decision making of high complexity, the 
documentation does not support a comprehensive history. Therefore, all three necessary criteria for reporting 
code 99306 have not been met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99306 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99306 billed for date of service June 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy with therapeutic exercises. 
 
You asked the Plan to pre-approve aquatic therapy with therapeutic exercises. You say that you currently have 
four tendons that are torn in your rotator cuff, and water therapy assisted in treating the tears. You also say that 
you were previously approved for this service. The Plan denied your request. The Plan says aquatic therapy 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 aquatic therapy with therapeutic 
exercises. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found aquatic therapy offers advantages for rehabilitation when a person is 
unable to attain positions on land that are useful for therapy or strengthening. Therapy also offers advantages 
for strengthening proximal muscles when distal muscles are not fully functioning. Our reviewer found that 
aquatic therapy should transition to land therapy. The advantages of therapy are not necessary to treat your 
condition. Our physician reviewer found that you do not have paralysis, and your range of motion is not limited 
on land compared to water. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy with therapeutic exercises have not been met. Therefore, we 
decided that the Plan does not have to pre-approve aquatic therapy with therapeutic exercises.
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 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 
pubic and sacral fractures after being kicked by a bull. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Amvuttra injection. 
 
You asked the Plan to pre-approve Amvuttra. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not prescribed for a medically 
accepted indication. 
 
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 Amvuttra. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested drug is being prescribed for cardiac amyloidosis. The FDA has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Amvuttra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Amvuttra injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva Respimat. 
 
You asked the Plan to pre-approve Spiriva Respimat. The Plan denied your request. The Plan says this drug is 
not covered under the enrollee's Part B plan. 
 
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 Spiriva Respimat.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health care services. 
 You asked the Plan to pre-approve continued home health care services. You say that you feel you have 
benefited from the home care and would like to continue this. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued home health care services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the documentation indicates that you continue to have some degree of restricted range of motion of the bilateral 
knee joints. However, your lower extremity motor strength is noted to be four out of five. Our reviewer found 
that your recent motor strength and range of motion has not significantly changed with continued physical 
therapy. You continue to require stand by assistance with transfers and ambulating with a walker. However, 
this level of assistance does not require the services of a skilled physical therapist without continued 
documented improvement in function, range of motion and motor strength. Our physician reviewer found that 
therefore, the additional of home health physical therapy cannot be considered 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 continued home health care services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued home health care services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex (J7312). 
 
You asked the Plan to pre-approve Ozurdex. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and 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 Ozurdex. Our reviewer says that 
Ozurdex is not medically reasonable and necessary for the enrollee. Our physician reviewer found Ozurdex is 
not FDA-approved for the enrollee's diagnosis of cystoid macular edema (CME). The requested use is not 
supported by Centers for Medicare & Medicaid Services (CMS) approved compendia or medical journals. Our 
reviewer found that the use listed is not indicated, supported, or recommended in any of the compendia. Our 
Physician reviewer found that Ozurdex is FDA-approved and supported for the diagnoses of macular edema 
after branch or central retinal vein occlusion, non-infectious posterior segment uveitis, or diabetic macular 
edema. Our reviewer also found that the enrollee is not identified as having any of these diagnoses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex (J7312).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G7 CGM. The Plan denied your request. The Plan says as this 
enrollee is not on insulin and does not have documentation of history of problematic hypoglycemia, the denial 
of a therapeutic continuous glucose monitor is upheld. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G7 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 You asked the Plan to pre-approve Orencia. You say that Orencia is medically necessary. The Plan denied your 
request. The Plan says a trial of Inflectra or Renflexis is required before alternatives can be considered. 
 
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 Orencia. Our reviewer says that 
Orencia is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.