Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and home health skilled 
nursing. 
 You asked the Plan to pre-approve home health services. You say that this is 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 doesnt support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 home health physical therapy and home health skilled nursing.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service July 28, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service billed is not supported. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99284. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented to the emergency 
department with puncture wound of the finger on July 28, 2023. The documentation from this date describes the enrollee as having the ability to move the finger in all directions, had a normal x-ray, and was given Keflex 
and told to follow-up with his doctor as outpatient. The enrollee was stable medically otherwise and did not 
require complex care or testing. Although the documentation supports an appropriate history and examination, 
it does not support moderate level of medical decision making. Therefore, the code billed is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 for date of service July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
03, 2023. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you have previously 
received the same injection and have never had to pay $500.30. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay $500.30 coinsurance, which is 20% of the allowed 
amount for a Medicare Part B drug injection ($2,501.50 allowed x 20% = $500.30). Therefore, we decided that 
the Plan does not have to waive the coinsurance for a denosumab injection provided on March 03, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304). 
 You asked the Plan to pre-approve Zilretta. You say that Zilretta is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Zilretta 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 Zilretta. Our reviewer says that 
treatment with Zilretta is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of triamcinolone acetonide before they will approve the requested drug. The 
requested drug is a new start. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zilretta (J3304).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that admission to an LTACH 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has multiple acute medical problems including heart failure and acute kidney 
injury. Their condition is complicated by hypotension (being managed with midodrine) and intermittent 
hypoxia. The enrollee currently requires daily physician visits and an inpatient level of care. It appears that the 
enrollee's medical needs at this level of care will meet or exceed 25 additional days. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel provided on 
March 17, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is urinalysis 
with urine culture and sensitivity. The Plan says that the PCR testing is considered unproven and 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 pay for the urine PCR panel. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was evaluated for dysuria using urine PCR. The sample was collected from diaper. 
It is unclear why a straight catheter sample was not collected. The choice of a urine PCR is not medically 
necessary, reasonable or 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for a urine polymerase chain reaction (PCR) panel provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service July 21, 
2023.   
You asked the Plan to pay for procedure code 88377. You say that the requested services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed number of units are not 
supported by the records as both provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE.  
 
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 88377. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found that the enrollee completed 11 
units in the analysis rather than the approved limit of 5 units. The documentation provided, however, did not 
clearly explain why the excess units would be appropriate for the enrollee or lead to improved outcomes for the 
enrollee to help justify the extra testing. The excess 6 units will be considered not medically necessary without 
sufficient support.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88377 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88377 billed for date of service July 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darzalex faspro (J9144) and carfilzomib (J9047). 
 
You asked the Plan to pre-approve the medications. You say that these medications are medically necessary for 
treatment of the enrollee's condition. The Plan denied your request. The Plan says routine costs for a clinical 
trial are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medications as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve darzalex faspro (J9144) and carfilzomib (J9047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg and a vacuum socket system and 
advanced foot with ankle, and advanced foot with ankle feature (L5781, L5988). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no compelling clinical justification for vacuum assisted suspension systems 
(VASS). 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a need for a new socket. The requested device has not been shown to be superior to 
other standard treatments for the medical condition. The requested vacuum assisted socket system (VASS) for 
the prosthesis is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new prosthetic leg and a vacuum socket system and advanced foot with ankle, and 
advanced foot with ankle feature (L5781, L5988).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF services are medically necessary.  
The Plan denied your request. The Plan says admission to a SNF is not medically necessary.  
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet 
the requirements for approval. 
 
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 that the enrollee has medical issues, some of which are active but not complex 
enough to require the higher level of care provided in an LTACH. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has not been released from daily wound 
treatment and skilled nursing continues to be required. You also say that the daily wound dressing changes 
provided at the SNF are a critical component of the enrollee's required skilled nursing and rehabilitation. The 
Plan denied your request. The Plan says continuation of SNF services is not medically necessary.  
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat gastric bypass duodenal switch (43659). 
 
You asked the Plan to pre-approve repeat gastric bypass duodenal switch. You say that this is medically 
necessary. The Plan denied your request. The Plan says guidelines do not support repeat bariatric surgery. 
 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 repeat gastric bypass duodenal switch. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while the traditional treatment for medically refractory reflux after 
sleeve gastrectomy is conversion to Roux-en-Y gastric bypass, the same effect would be expected from 
duodenal switch because of the altered foregut anatomy and there are some data to support this. However, there 
is a lack of documentation of medical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat gastric bypass duodenal switch have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat gastric bypass duodenal switch (43659).
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 if the enrollee goes to a lower level of rehab, it will 
compromise them from achieving the highest level of functional outcome and their ability to reintegrate back in 
their community. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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.