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

 
We decided that the Plan does not have to pay for Nulojix (code J0485) provided on August 25, 2022. 
 
You asked the Plan to pay for Nulojix. You say that this drug was medically necessary for the patient. The Plan 
denied your request. The Plan says this drug is considered experimental/investigational for the patient's 
condition. 
 
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 pay for Nulojix. Our reviewer says that the use of 
this drug was not medically necessary. Our physician reviewer found The enrollee is status post liver transplant. Nulojix powder, lyophilized, for solution for Intravenous injection; a selective T-cell co stimulation 
blocker is indicated for prophylaxis of organ rejection in adult patients receiving a kidney transplant. It is used 
in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids. Some limitations of 
use are that it can only be used in patients who are EBV seropositive, and it safe use has not been established 
for the prophylaxis of organ rejection in transplanted organs other than the kidney. Nulojix should never be 
used in patients with unknown aerostats or EBV seronegative. Use in patients with history of liver transplant is 
not recommended and only physicians experienced in immunosuppressive therapy and management of kidney 
transplant patients should prescribe Nulojix. 
 
The review has determined that the requested use of Nulojix 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 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 Nulojix have not been met. Therefore, we decided that the Plan does not have to 
pay for Nulojix (code J0485) provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NPWT pump and associated supplies for month 3 
(E2405 and A6550). 
 You asked the Plan to pre-approve the DME. You say that therapy will be disrupted, and the wound will get 
larger. The Plan denied your request. The Plan says your records show that your wound increased in size from 
February to March in 2023; therefore, the request is not 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 DME. Our physician reviewer 
found based on the medical records provided wound healing has failed to occur from February 9, 2023, through 
March 31, 2023, and provided records in this case do not document that the negative pressure wound therapy 
pump at issue in this case meets all Medicare criteria that is medically reasonable and 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a NPWT pump and associated supplies for month 3 (E2405 and A6550).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palliative home health services. 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled palliative care nursing services to 
provide treatment that is medically necessary. The enrollee does not require additional palliative care skilled 
nursing services to effectively provide treatment, care, and/or services in order to improve the enrollees 
condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
The enrollee has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve palliative home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 28, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that this was a medically necessary 
admission. The Plan denied your request. The Plan says this should have been billed as outpatient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the hospital with a 4-day history of nausea and 
vomiting. He was found to have hyponatremia, hypokalemia, acute kidney injury and was confirmed with 
COVID-19 infection. found to have hyponatremia, hypokalemia, AKI and was confirmed with COVID-19. 
infection. The hospital course was intravenous fluids and medications for electrolyte abnormalities, and an anti-
emetic. He remained on room air with good oxygen saturation. The enrollee was discharged on the same day to 
follow up with his primary provider.  
 
The record does not show that at the time of inpatient admission the admitting physician reasonably expected 
that the enrollee's necessary hospital care would span two midnights. Care at the observation level appears to 
have been appropriate with the option to transition the enrollee to inpatient status if their condition warranted 
further hospital level 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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided on July 28, 2022.
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 you have provided medical records to 
support transfer to a LTACH. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 patient is an 80-year-old female who was admitted to the acute care hospital with 
acute right basal ganglia hemorrhage with intravascular extension requiring intubation, emergent external 
ventricular drain placement, which was later removed, trach placement, and PEG placement. Recent notes describe the patient as now off vent support, tolerating oxygen weaning via trach and no longer requiring 
surgery. She is tolerating tube feeds and requires ongoing wound care and dialysis. The patient appears to be 
improving with current treatment and should only require short-term additional acute care services that can 
safely be provided at the current facility until more appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment at 
the current facility is 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 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 pre-approve semi-electric hospital bed (E0260), side rails (E0310) 
and mattress innerspring (E0271). 
 
You asked the Plan to pre-approve the DME. You say that you are not getting any rest and are in pain. The 
Plan denied your request. The Plan says you do not meet criteria for a semi-electric hospital bed. 
 
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 DME. Our physician reviewer 
found the record does not show you do not require positioning or frequent change in position not possible with 
standard bed. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve semi-electric hospital bed (E0260), side rails (E0310) and mattress innerspring (E0271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that this visit should be paid as it was medically 
necessary. The Plan denied your request. The Plan says payment for this visit is included in the payment made 
for the prior surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment for global surgery includes follow-
up visits. Modifier -24 is to be used to report a visit that is unrelated to the surgery and is separately payable.  
 
We looked at the file and Medicare rules. This visit was provided within the 90-day global period of surgery 
described by code 57250. It was not reported with a modifier to indicate it was unrelated to the surgery. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that a portable ventilator is medically 
necessary. The Plan denied your request. The Plan says the ventilator is non-covered because it would be set in 
assist-control (AC) mode with very low tidal volumes that could be delivered by a bi-level positive airway 
pressure (BiPAP.) 
 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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the documentation shows that 
the home ventilator is being requested for use with very low set tidal volumes which could be provided by a 
BiPAP device with average volume-assured pressure support (AVAPS) and a back-up rate. Provided records 
do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional outpatient therapy services (97110 x 12). 
 
You asked the Plan to pre-approve the therapy services. You say that the services are necessary for the enrollee 
to continue receiving the care needed. The Plan denied your request. The Plan says the enrollee has been in 
therapy the past several months and the enrollee's pain has improved, the enrollee been instructed on how to do 
home exercises.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's medical condition and therefore, 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional outpatient therapy services (97110 x 12).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication 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 medication. Our physician reviewer 
found the requested use of Opdivo is not FDA-approved for the enrollees diagnosis. The 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 Opdivo (J9299).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your functional status does not require daily skilled therapy. You not have daily 
skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is medically necessary. The 
Plan denied your request. The Plan says that the requested power scooter is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the documentation does not support 
that you are unable to use a manual wheelchair to accomplish mobility-related self-care tasks at home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93975 billed for date of service August 31, 2022. 
 
You asked the Plan to pay for code 93975. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says the medical records do not support payment of code 93975 for 
date of service August 31, 2022. 
 
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 93975 is Duplex scan of arterial inflow and venous 
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study. 
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 93975. Our reviewer says that code 9395 is not 
supported by the medical record. Our reviewer found in this procedure, the provider performs a complete study of the abdominal, pelvic, scrotal, and or retroperitoneal organs using duplex ultrasound. He performs the 
procedure to examine the vascular supply to the organs involved as well as the venous return. This procedure 
was not found in medical record. 
 
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 93975 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93975 billed for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on November 3, 2022. 
 
You asked the Plan to pay for the office visit. You say that the previous office visits billed are not the same 
specialty as the provider that billed a new office visit on November 3, 2022. The Plan denied your request. The 
Plan says the specialty and group are the same for the providers the enrollee received services from. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 Review of the file shows that this enrollee has seen a previous provider within the same group and same 
specialty on the date of service October 12, 2022. Since the enrollee has seen another provider of the same 
group and specialty within the previous three years, a new patient evaluation and management charge would 
not be appropriate for this service. An established patient evaluation and management code would appear to 
better reflect the services rendered. Based on this information, we decided that Medicare rules for coverage of 
the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit 
(99204) provided on November 3, 2022.