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 required services cannot be safely provided with 
home health or skilled nursing at this time. The Plan denied your request. The Plan says that the enrollee does 
not meet all of the requirements for IRF admission. 
 
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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes 
A41.59 and E43 rendered from May 27, 2021, to June 8, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.59 (other gram-negative 
sepsis) and E43 (unspecified severe protein-calorie malnutrition. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not support the reporting of either diagnosis code. The documentation does not meet the 
criteria for SOFA (The Sequential Organ Failure Assessment (SOFA). The enrollee did have signs/symptoms 
of mental confusion, but the documentation shows that this was due to Alzheimer's dementia. Therefore, the 
records do not support diagnosis code A41.59. 
 
In terms of E43, the medical record does not include sufficient documentation to confirm severe protein-calorie 
malnutrition. The documentation does not support involuntary weight loss, body mass index, or reduced muscle 
mass. There was no consistent diagnosis of plan of care for this diagnosis throughout the hospital stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis codes A41.59 and E43 rendered from May 27, 2021, to 
June 8, 2021.
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 full and functional criteria for 
admission to the IRF and that this level of care would ensure maximal gains following the enrollee's discharge 
from the current short-term acute hospital. The Plan denied your request. The Plan says the requested IRF 
services are 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 the complexity of the enrollees 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. 
Medically necessary care can be provided in a different level of care. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, doxorubicin HCL liposome, dexamethasone 
sodium phosphate, famotidine, and diphenhydramine HCL. 
 
You asked the Plan to pre-approve Keytruda, doxorubicin HCL liposome, dexamethasone sodium phosphate, 
famotidine, and diphenhydramine HCL. You say that this is medically necessary. The Plan denied your request. 
The Plan says this regimen is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda, doxorubicin HCL liposome, 
dexamethasone sodium phosphate, famotidine, and diphenhydramine HCL. Our reviewer says that the requested use of this drug combination is not supported. Our physician reviewer found the requested use of 
these drugs is not FDA-approved for the enrollee's diagnosis. here is insufficient support in the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal for the requested regimen.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, doxorubicin HCL liposome, dexamethasone sodium phosphate, 
famotidine, and diphenhydramine HCL have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda, doxorubicin HCL liposome, dexamethasone sodium phosphate, famotidine, and 
diphenhydramine HCL.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services provided in the Hellenic Republic 
from June 7, 2022, to October 31, 2022. 
 
You asked the Plan to pay for chemotherapy services. You say that the enrollee needed to continue 
chemotherapy. The Plan denied your request. The Plan says this provider was out-of-network with the Plan and 
authorization was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered under limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency and urgent care services. Urgently needed services are defined as those needed 
because of an unforeseen illness or condition and it is not reasonable to get the services from the Plan. 
 
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 chemotherapy services. Our review says that 
these services do not meet criteria for payment. Our reviewer found that the enrollee could have foreseen 
requiring these services prior to leaving the Plans service area. Therefore, these services do not qualify as 
urgent care. 
 
We looked at the file, Medicare rules, the Plans rules, and our physicians review. These services do not fall 
within any of Medicares specified circumstances for coverage of services outside of the United States. 
Additionally, these services do not meet the Plans rules for coverage because they were not emergent or urgent 
in nature. Therefore, we decided that the Plan does not have to pay for chemotherapy services provided in the 
Hellenic Republic from June 7, 2022, to October 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the requested treatment order of Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that this drug is not 
FDA-approved for squamous cell carcinoma of the lung. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you have tried cortisone injections 
without much relief and have endured severe pain for the past 20 years. You say the procedure could help bring 
a pain-free life. The Plan denied your request. The Plan says the Intracept procedure 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 the Intracept procedure. 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 magnetic resonance imaging (MRI) showing only modic endplate 
changes. This means that the cause of your back pain is unclear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide for 21 hours a week. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee is not mobile and needs 
additional assistance. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that clinical 
documentation shows that the enrollee has functional and cognitive impairments. However, there is no clinical 
reasoning or changes to the documented plan of care given in which additional home health aide hours would 
be medically necessary, thus 3 additional hours daily for home health aide services are not 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home health aide for 21 hours a week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code S9988. 
 
You asked the Plan to pre-approve procedure code S9988. You say that the services are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9988 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9988 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9988 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S9988.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has been lying in bed for two weeks 
getting weaker and needs to be sent for rehabilitation to regain their strength.  The Plan denied your request. 
The Plan says that the enrollee does not meet the Medicare guidelines for services in a SNF.  
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee is below functional baseline, and 
physicians document acute on chronic cognitive impairment. Evaluating therapists recommend ongoing daily 
skilled therapy in a skilled nursing facility with good rehabilitation potential. The clinical documentation states 
the enrollee is a fall risk, requires frequent laboratory draws with electrolyte derangement, status post failure to 
thrive and rhabdomyolysis, thus the enrollee would benefit from frequent assessment by skilled nursing. 
Clinical documentation shows that the enrollee requires daily skilled services on an inpatient basis in a skilled 
nursing facility.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 99601. You say that these are Medicare-covered services and are 
not restricted by Medicare policy. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 26, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that the provider was not aware he was out-of-
network. The Plan denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on January 26, 2023, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee or hip 
disarticulation, knee extension assist (L5850). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says L5850 is not appropriate for this prosthesis. 
 
Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional 
need for the technologic or design feature of a given type of foot. 
 
Based on the Pricing, Data Analysis, and Coding (PDAC) Durable Medical Equipment Coding System, the 
remaining denied code - L8550 - is not considered appropriate to request for the OttoBock C-Leg. A review of 
the PDAC coding system shows that this approved leg is only coded with L5828, L5845, L5848, and L5856. 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 pre-approve addition, endoskeletal system, above knee or 
hip disarticulation, knee extension assist (L5850).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network dermatology referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says care must be received from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network dermatology referral.
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 are requesting reconsideration for the denial of 
an IRF admission. You say the decision to deny your request will have a profound impact on your health, well-
being, and chances of a full recovery. The Plan denied your request. The Plan says you do 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.