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

 
We decided that the Plan does not have to pay for lab testing (87481, 87798) provided on October 5, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab testing have not been met. 
Therefore, we decided that the Plan does not have to pay for lab testing (87481, 87798) provided on October 5, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging. 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that this service is medically 
necessary. The Plan denied your request. The Plan says parathyroid planar imaging is not medically necessary. 
The member has a history of secondary hyperparathyroidism of renal origin. There is no mention of this test 
being ordered for preoperative planning purposes, or of a referral to surgery. The physical exam of the neck is 
normal. Parathyroid gland imaging is indicated only for the preoperative localization and evaluation of 
parathyroid tumors. There is no concern expressed for the presence of a parathyroid tumor. We do not have 
parathyroid hormone or calcium concentration measurements and the medical records are from the member's 
primary care doctor and make no mention of a specialty surgery referral or consultation or plan for surgical 
intervention. 
 
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 parathyroid planar imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the provided records in this case do not document any details as to the 
necessity of the imaging such as a planned surgery or any other acute signs or symptoms related to the 
hyperparathyroidism or parathyroid gland.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parathyroid planar imaging.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab. 
 
You asked the Plan to pre-approve durvalumab. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 durvalumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of durvalumab 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 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 durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code J96.91 
rendered from March 12, 2021, to March 18, 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 code J96.91. 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 provided documentation did not sufficiently support acute respiratory failure as they 
did not require high flow oxygen, bilevel positive airway pressure (BiPAP), or vent support, and did not have 
severe enough respiratory distress to meet the definition of this diagnosis. Therefore, the code, J96.91 is not 
supported for this admission.   
 
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 code J96.91 rendered from March 12, 2021, to March 18, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says a home ventilator is not medically necessary. The 
patient's needs can be met with bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS). 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the provided records document 
that the home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee was only identified as 
having a dementia. According to the applicable NCD, a PET scan of the brain is covered for use in individuals 
who meet diagnostic criteria for both AD and FTD. The records suggest that the enrollee most likely has AD. 
However, there was no mention of a consideration of FTD. Therefore, a PET scan cannot be covered at this 
time. 
 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 PET scan have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Health Plan. The Health Plan has approved ongoing 
care in the current acute care setting.  
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (62321). 
 
You asked the Plan to pre-approve a steroid injection. You say that the requested injection is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that an ESI will be considered medically reasonable and 
necessary when the enrollees history, physical examination, and concordant radiological image-based 
diagnostic testing support radiculopathy, post-laminectomy syndrome, or acute herpes zoster associated pain.  
 
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 steroid injection. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the enrollee does not have an 
evidence-based indication for a cervical epidural steroid injection. 
 
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 steroid injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cervical epidural steroid injection (62321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on October 3, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for surgical services. You say that this should be covered. 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 surgical services provided on October 3, 2022, by 
an out-of-network (OON) provider.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev. 
 
You asked the Plan to pre-approve Zirabev. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Zirabev. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Zirabev is not FDA-
approved for the enrollees diagnosis when used in combination with pembrolizumab. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a 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 Zirabev have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zirabev.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient mental health admission. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the needed services can be safely provided 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that it was not 
expected this enrollee would improve in a reasonable period of time beyond the dates in question as the 
enrollee was not showing any dangerousness to self or others, auditory or visual hallucinations and without 
aggressive behaviors while not showing any acute threats of 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 he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. The health plans denial of continued inpatient psychiatric services 
appears appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an inpatient mental health admission.
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 enrollee requires a high level of care and 
aggressive therapy before returning home. The Plan denied your request. The Plan says the enrollee's needs 
may be met in a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for transfer or transplant of single tendon rendered on October 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 27691 is "Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior 
tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal 
tendon to midfoot or hindfoot)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite the flexor 
hallucis longus tendon was identified and sutured into the dorsal extensor hallucis longus tendon. Therefore, 
the records do support that CPT 27691 was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
transfer or transplant of single tendon rendered on October 26, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care provided from 
May 27, 2023, through May 28, 2023. 
 You asked the Plan to pre-approve SNF care. You say that since the stroke at the end of March, the enrollee is 
not much better, and easily weak. The Plan denied your request. The Plan says the enrollee has weakness and 
needs bathroom assistance, this does not require a skilled nursing facility 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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the skilled nursing facility (SNF) care provided from May 27, 2023, through May 28, 2023.