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

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric admission. 
 
You asked the Plan to pre-approve continued inpatient psychiatric admission. You say that the enrollee 
continues to require inpatient hospitalization. The enrollee is still experiencing rapid mood swings, cannot 
contract for safety of the unit, and is undergoing several medication changes. The Plan denied your request. 
The Plan says continued stay at the inpatient behavioral health level of care for this admission is not medically 
necessary beginning June 21, 2023. The service the enrollee needs can be provided safely in other settings. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric 
admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found based 
upon review the records provided, it was not expected this enrollee would improve in a reasonable period of 
time for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others and was compliant with her treatment. The health plans denial of continued inpatient psychiatric 
services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the 
date in question as she was not a danger to herself or others and does not have auditory or visual hallucinations. 
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services were reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond 
the date in question. The reviewer is unable to find an individualized treatment plan, however, the entire record 
is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review 
the records provided for the admission of this enrollee does not meet the criteria for June 21, 2023, forward as 
this enrollee was not shown to be a danger to herself or others, delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
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 inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits and prolonged care provided from 
September 26, 2022, to November 21, 2022. 
 
You asked the Plan to reimburse you for the physician services. You say that this provider does not accept 
health insurance.  The Plan denied your request. The Plan says the provider in this case does not participate 
with Medicare. The Plan also says payment cannot be made for services performed by a provider that does not 
participate with Medicare. 
 
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 reimburse you for the office visits and prolonged 
care provided from September 26, 2022, to November 21, 2022.
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 you are not fit to go home, you are in a weak state 
and are too big for your wife to support and you need IRF services to return to your baseline. 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you 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 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85025 and 80048 billed for date of service 
January 20, 2023. 
 
You asked the Plan to pay for procedure codes 85025 and 80048. The Plan denied your request. The Plan says 
procedure codes 85025 and 80048 are not payable. 
 
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 codes 85025 and 80048 have a status indicator of X on the Physician Fee Schedule. 
This means that procedure codes 85025 and 80048 are not payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 85025 and 80048 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 85025 and 80048 billed for date of service January 20, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that the enrollee has been receiving Aflibercept (Eylea) 
for over five years, and needs a stronger medication. The Plan denied your request. The Plan says this request 
does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Vabysmo. Our reviewer says that the 
enrollee does not meet the coverage criteria for Vabysmo. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. The Plan denied your request. The Plan says the step therapy 
criteria have 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 Vabysmo. Our reviewer says that 
Vabysmo is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Avastin and Lucentis before they will approve the requested drug. You do not have a history of an osteoporotic 
fracture and have not tried and failed the required drugs. Our reviewer also found that there is no 
documentation provided indicating that the Plans required drugs would likely be less effective and/or likely 
have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not Medicare guidelines for services 
in 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. 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99225 billed for dates of service January 10, 
2023, to January 11, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was denied incorrectly. The Plan 
denied your request. The Plan says the code is no longer valid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99225 is not supported. Specifically, code 99225 is not payable for services provided in 
20223. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99225 billed for dates of 
service January 10, 2023, to January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis, tumor immunohistochemistry, 
quantitative or semiquantitative, each antibody (88361) provided September 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting that this claim is 
reprocessed following Medicare policy, it should not be denied as experimental and investigational. The Plan 
denied your request. The Plan says this service does not meet the medically necessary requirements. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of gastroesophageal reflux disease (GERD). The wide area 
transepithelial sampling with three-dimensional analysis (WATS3D) is performed during endoscopic 
examination of the esophagus. The computer-assisted brush biopsy procedure is intended as an adjunct to 
standard four-quadrant forceps biopsy for screening or surveillance of cancerous or precancerous esophageal 
lesions and Barrett esophagus (BE). Because combined use of WATS3D with standard screening is intended to 
replace the current standard of care for guiding patient management decisions regarding initiation of treatment 
or surveillance, direct evidence of clinical utility is required. The evidence is insufficient to determine that the 
technology results in an improvement in the net health outcome. The review has determined that the 
items/services at issue in this case are not medically reasonable or 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for morphometric analysis, tumor immunohistochemistry, quantitative or 
semiquantitative, each antibody (88361) provided September 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says there is insufficient 
evidence to determine the safety and effectiveness of the Intracept procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an 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 
without facet joint disease or foraminal stenosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 20, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Triage test billed for date of service October 
3, 2022. 
 
You asked the Plan to pay for the testing services. You say that molecular diagnostic testing is becoming 
common practice. The Plan denied your request. The Plan says the testing is considered investigational. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Triage test 
billed for date of service October 3, 2022.
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 February 21, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the medical records submitted support the need for the ambulance services and you 
would like for the plan to reconsider payment. The Plan denied your request. The Plan says the ambulance 
services were not medically necessary. 
 
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 was not 
medically necessary. Our physician reviewer found the transportation via ambulance from the hospital to your 
residence was not medically necessary. You 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 your 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 February 21, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on December 5, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says that the code used to report the services provided 
is not supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that drugs 
from 15 drug classes were tested in this case. Based on this information, we decided that Medicare rules for 
coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on December 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on February 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the billed services not supported in the medical record. Specifically, the documentation provided 
does not include records for the date of service at issue. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health services provided on February 22, 2022.
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 this is needed for the enrollee's condition. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. The Plan also says 
that they will approve use of the ventilator for 3 months to allow time to get the enrollee the appropriate 
breathing device. 
 
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.