Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a save and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is 
not a reasonable expectation that the enrollee 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 an 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. You say that the doctor says you need intense rehabilitation. You 
say you still can't walk, but there is potential if you get the right kind of therapy. The Plan denied your request. 
The Plan says an IRF stay 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the code used to report the service provided 
is not supported in the medical record. This service would be better reported with a more appropriate 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 76770 is ultrasound, retroperitoneal (e.g., renal, aorta, 
nodes), real time with image documentation; complete. 
 
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 76770. Our reviewer says that this code is not supported for the service provided. Our reviewer found the medical records provided does not include 
sufficient documentation to validate that an ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with 
image documentation; complete was the procedure that was performed on August 1, 2022; therefore, this 
procedure cannot be verified. 
 
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 76770 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76770 billed for date of service August 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
  You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria has not been met. 
 
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 Feraheme. Our reviewer says that the 
enrollee has not tried and failed the Plan's preferred step one alternative. Our physician reviewer found that the 
record does not indicate the enrollee has a contraindication to or would have an adverse effect from the 
preferred step one alternative. The elements of the coverage criteria are not satisfied, and the requested drug 
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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 require extensive therapy and have made 
progress in your current facility but are now ready to move into acute rehab. The Plan denied your request. The 
Plan says you do not meet the criteria for admission to an 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 22, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service November 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that signature requirements have been met. The Plan 
denied your request. The Plan says the billed services are not supported. The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the medical documentation.  
 
We looked at the file and Medicare rules. In this case, the records do not show a specific test ordered by the 
physician. There are no medical records from the treating physician to show that the testing correlates with 
given interventions. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 04, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on January 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the 
requested device is medically necessary due to lymphedema. The Plan denied your request. The Plan says 
medical records received from the enrollees doctor does not meet criteria that shows a medical reason on why 
the enrollee needs the requested device and appliance. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet criteria for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules state endovenous ablation therapy is only covered under 
certain indications. 
 
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 endovenous ablation therapy. Our 
reviewer says that the enrollee does not meet criteria for endovenous ablation therapy. Our physician reviewer 
found it is not possible to attribute the enrollee's leg pain, weakness, and difficulty walking to varicose veins 
without an assessment of lower extremity arterial perfusion. It is documented that the enrollee has multiple risk 
factors for peripheral arterial disease (PAD) including diabetes and hypertension and has diminished pulses. It 
is also documented that the enrollee required previous lower extremity arteriography bilaterally. Additionally, 
criteria require documentation of reflux of greater than 500 milliseconds in the saphenous vein to be treated. 
The reflux in the residual, previously treated right great saphenous vein is described as minimal and less than 
500 milliseconds in duration. Therefore, medical necessity has not been demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets.  
You asked the Plan to pre-approve the medication. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although the requested ondansetron may sometimes be covered by Medicare Part B, the 
requested use does not fall within Medicare Part B coverage because it is not being used as a full therapeutic 
replacement for intravenous anti-emetic drugs that would have otherwise been administered at the time of a 
particular chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve 
ondansetron tablets.  
 
Benefits for the medication 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 13, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that based on the enrollee's medical condition, no other mode of transport was appropriate. 
You also say that any lesser mode of transport was contraindicated and may have compromised the health and 
well-being of the enrollee. The Plan denied your request. The Plan says this request is not medically necessary 
because the enrollee does not meet the criteria requirements outlined in Medicare rules for this service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport, and ground mileage.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance upon discharge for rehabilitation was not medically necessary. The enrollee did 
not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport, and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 25, 2022, to 
August 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you already billed a NOA and there is no 
need of a NOA for every claim. The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 26, 2022. The NOA was not received by the Plan until December 15, 
2022. As more than 30 days passed since the timely filing date and the NOA receipt, no payment can be made 
on this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from July 25, 2022, to August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart without 
contrast, with a quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the clinical information 
provided does not indicate that the enrollee meets the criteria. 
 
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 the CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence showing that the use of coronary artery calcium (CAC) scores in clinical 
management of asymptomatic individuals leads to changes in patient management or in individual risk 
behaviors that improve cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental and investigational for the evaluation and management of this enrollee's medical condition. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the heart without contrast, with a quantitative evaluation of 
coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and a bilevel positive airway 
pressure (BiPAP) device with average volume-assured pressure support (AVAPS) mode would meet all of the 
enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that it will help the enrollee control their glucose 
monitoring. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM which 
requires either low blood sugars or insulin use. There is no mention of low blood sugars or insulin use, this 
does not mean that the CGM would not be beneficial for the enrollee; it does mean that the CGM coverage 
criteria was 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).