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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 no documented need for intensive rehabilitation services. Medically 
necessary rehabilitation services can 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service January 5, 
2023. 
 You asked the Plan to pay for procedure code 99231. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99231 is bundled into payment for code 62328. 
 
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, we have confirmed that code 99231 
is a column II code to column I code 62328. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 99231 billed for date of service January 5, 2023.
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 did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the patient does not require transfer to a LTACH. 
The patient's needs can be met at the current acute care hospital as long as 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 acute hospital where the patient currently is can provide for all the patients 
present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. The 
provided records do not explain what care services will be provided in the LTACH that are not available in the present hospital setting.  The patient is presently receiving appropriate services in the acute care setting; 
stability for transfer is not clear given the new rectal bleeding. Continued care in the short-term acute hospital 
is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99305) rendered 
on November 3, 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 Current Procedural Terminology (CPT) code 99305 remains 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 99305 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's 
facility floor or unit." 
 
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 not supported by the medical records. Our reviewer found that the note did not support the 
evidence of a comprehensive history or decision making of moderate complexity. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for initial nursing facility care (procedure code 99305) rendered on November 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ipilimumab and nivolumab. 
 
You asked the Plan to pre-approve the medications. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the requested treatment order of ipilimumab 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 medications. Our reviewer says that 
the requested drug combination is not supported. Our physician reviewer found that the record indicates the 
enrollee has a diagnosis of non-small cell lung cancer with brain metastases. The Food and Drug 
Administration has not stated that the requested drug regimen is indicated for the enrollee's specific condition. 
The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug regimen in the enrollee's specific clinical situation. No literature from Medicare-approved cancer journals 
was submitted for review. 
 
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 medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ipilimumab and nivolumab.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement group 2 power wheelchair with accessories. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the condition of your 
wheelchair is very poor. The Plan denied your request. The Plan says that the doctors notes sent with this 
request do not include sufficient information on your mobility limits, and there was no wheelchair assessment 
provided. The Plan also says for this reason, you do not meet criteria.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not supplied records to indicate why it will not replace a previously 
approved power wheelchair and has not addressed the fact this is a replacement request. Therefore, we decided 
that the Plan has to pre-approve a replacement group 2 power wheelchair with accessories.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient psychiatric hospital admission provided from 
November 2, 2022, to November 7, 2022.  
 You asked the Plan to pay for the inpatient psychiatric hospital admission. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the inpatient psychiatric hospital services 
were not medically necessary. The treatment needs could have been met at a less restrictive setting.  
 
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 pay for the inpatient psychiatric hospital admission. 
Our reviewer says that the requested inpatient psychiatric hospital admission is not considered medically 
necessary in this case. Our physician reviewer found that based upon review the records provided it was not 
expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or 
others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. 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 as he did not have dangerousness to self or others, perceptual disturbance including 
delusions, auditory or visual hallucinations. This enrollee did not appear to require inpatient mental health 
treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that 
active treatment was taking place. It did not appear that the services were reasonably expected to improve the 
patients condition or for the purpose of diagnosis. 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 criteria 
for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others, 
no auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while 
not showing any aggressive behaviors. 
 
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 inpatient psychiatric hospital admission have not been met. Therefore, we 
decided that the Plan does not have to pay for an inpatient psychiatric hospital admission provided from 
November 2, 2022, to November 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ado-trastuzumab emtansine (Kadcyla) (J9354 x 2) provided 
on November 15, 2022.  
 
You asked the Plan to pay for the drug. You say that the medical records support the use of this drug.  The Plan 
denied your request. The Plan says the drug is considered experimental and investigational and therefore is not 
covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the drug. Our physician reviewer found 
guidelines of the National Comprehensive Cancer Network (NCCN) and the Medicare-approved major drug 
compendia there is no documentation that the Kadcyla provided on November 15, 2022, at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pay for ado-trastuzumab emtansine (Kadcyla) (J9354 x 2) provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 88341-26 and 88342-26 for 
date of service February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the billed codes were valid on the date of service 
and should be payable. The Plan denied your request. The Plan says you billed with an incorrect diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that some International Classification of Diseases 
(ICD)-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. 
If no bilateral code is provided and the condition is bilateral, providers should assign separate codes for both 
the left and right side. If the side is not identified in the medical record, providers should assign the code for the 
unspecified side. 
 In this case, you billed the lab services in question with ICD-10 diagnosis codes of both C50.912 (Malignant 
neoplasm of unspecified site of left female breast) and C509.19 (Malignant neoplasm of unspecified site of 
unspecified female breast).  Both of these together cannot be true- either the condition exists in the left breast 
or in an unspecified breast, but you cannot bill both 'left' and 'unspecified' together.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with codes 88341-26 and 88342-26 for date of service February 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injection services (procedure codes J19855, J3411, J3415, J3420) 
rendered on September 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 
the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) J1955: 
 
Injection, levocarnitine, per 1 gm 
 
HCPCS J3411: 
 
Injection, thiamine hcl, 100 mg 
 
HCPCS J3415: 
 
Injection, pyridoxine hcl, 100 mg 
 
HCPCS J3420: 
 
Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 
 
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 not supported by the medical records. Our reviewer found that the record supports that all of 
these medications were administered as billed. The units of each drug administered in each injection were 
documented. 
 
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 
injection services (procedure codes J19855, J3411, J3415, J3420) rendered on September 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (81265, 81266) provided on July 20, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that the know error DNA Specimen Provenance 
Assay is a statutorily excluded test. 
 
We looked at the file and Medicare rules. The test performed is non-covered. 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 (81265, 81266) provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission providing updated clinical documentation to support the need for continued 
medical management in an acute IRF. The Plan denied your request. The Plan says the enrollee does 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 21, 2022, billed 
with code 77080. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says code 77080 is not supported when billed with 
diagnosis codes M35.00 and G62.9. 
 
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 77080 is Dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that bone density scans are often used to 
diagnose or assess your risk of osteoporosis, a health condition that weakens bones and makes them more 
likely to break. CMS require the test for a medical reason, such as high risk for osteoporosis, osteopenia, 
sudden pain, or an injury. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on September 21, 2022, billed with code 77080.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87631) provided on January 16, 2023. 
 
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 for this molecular pathology testing did not include the required 
unique identifier. 
 
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 lab testing have 
not been met. Therefore, we decided that the Plan does not have to pay for lab testing (87631) provided on 
January 16, 2023.