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

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services are 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 you are not 
shown to be homebound. As such, home health services are not medically necessary or reasonable. 
 
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 services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Yervoy. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee did not progress on carboplatinum and 
pemetrexed. The Plan denied your request. The Plan says that Yervoy 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 drug. Our reviewer says that Yervoy 
is medically necessary. Our physician reviewer found that the requested use of Yervoy is FDA-approved. 
Yervoy is also safe and effective and otherwise 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 been met. Therefore, we decided that the Plan has to pre-approve 
Yervoy.  
 
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 the acute inpatient hospital care provided from March 2, 
2023, to March 7, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that medically necessary services were 
rendered to the patient. The Plan denied your request. The Plan says payment is not allowed for this type of 
service because authorization was not approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee has type 2 diabetes mellitus and is on both oral medication and insulin 
therapy. The enrollee presented to the emergency department (ED) with hyperglycemia (396, >500, 487, 730, 
>900). The enrollee was diagnosed with acute on chronic kidney injury and oral thrush. The enrollee's insulin 
dosing was adjusted, they were started on fluids. Workup revealed hemoglobin (hgb) 6.7 with fecal occult 
blood test (FOBT) positive. The enrollee was admitted with plans for gastrointestinal (GI) consultation. 
Documentation from the endocrinologist included plans for outpatient GI workup, fluids and insulin 
management as well as continue fluconazole for thrush. The enrollee was given intravenous (IV) iron, blood 
transfusion. Vitals remained stable. Kidney function was already responding to fluids, and there was no acute 
bleeding noted. Therefore, it was not expected that the enrollee would have required hospital services that 
would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 2, 2023, to March 7, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health hospice services provided from January 1, 2023, 
to January 31, 2023. 
 
You asked the Plan to pay for the home health hospice services. You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says this claim was not filed with a valid CBSA 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health hospice claims must be filed with a 
valid CBSA code. In this case, the claim you submitted for the services in question do not include a CBSA 
code. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health hospice services have not been met. Therefore, we decided that the Plan does not 
have to pay for home health hospice services provided from January 1, 2023, to January 31, 2023.
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 had hip fracture and would greatly 
benefit from acute inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's condition 
does not meet the Medicare guidelines.  The Plan says that the services needed may be provided safely in a 
lower level of care.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 maximum assistance for self 
care and has limited mobility. You also say the enrollee is currently unable to climb stairs and has 9 stairs at 
home. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415) and 
a per mile allowance (P9603) billed for date of service June 9, 2022. 
 
You asked the Plan to pay for codes 36415 and P9603. You say that the services in dispute were medically 
necessary and should be paid. The Plan denied your request. The Plan says these codes are 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 36415 is collection of venous blood by venipuncture. The 
CPT Code Manual definition of code P9603 is per mile allowance. 
 
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 codes 36415 and P9603. Our reviewer says that the criteria 
for coverage have not been met. Our reviewer found the medical record includes documentation of a thyroid 
stimulating hormone (TSH) blood draw for date of service billed and code 36415 cannot be verified. The 
documentation does not support that travel was performed, and therefore code P9603 cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36415 and P9603 have not been met. Therefore, we decided that the Plan 
does not have to pay for the collection of venous blood by venipuncture (36415) and a per mile allowance 
(P9603) billed for date of service June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 80061, 81000, 82043, 82570, 84443, 
and 85025 billed for date of service April 25, 2022.  
 
You asked the Plan to pay for procedure codes 80053, 80061, 81000, 82043, 82570, 84443, and 85025. You 
say that you are a reference laboratory and were not provided correct insurance information at the time of claim 
submission. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan has already paid for one unit of each of these codes for this date of service. 
 
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 codes 80053, 80061, 81000, 82043, 82570, 84443, and 85025 is 1. The MAI 
value for this code is 3. You billed 2 units of each of these codes, exceeding the MUE. You did not provide all 
the required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 80053, 80061, 81000, 82043, 82570, 84443, and 85025 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 80053, 80061, 81000, 82043, 82570, 84443, and 85025 
billed for date of service April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for E-Stim with medication injections provided on March 6, 
2023. 
 
You asked the Plan to pay for E-Stim with medication injections. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the request is 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 E-Stim with medication injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 E-Stim with medication injections have not been met. Therefore, we decided 
that the Plan does not have to pay for E-Stim with medication injections provided on March 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional trips for routine transportation. 
 
You asked the Plan to pre-approve 72 additional trips for routine transportation. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you have exceeded your benefits for the 
benefit period. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 72 additional trips for routine transportation.
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 not able to walk from your bed to toilet 
without help, your having issues with healing on your foot healing and need wound care. You live alone and 
cannot be left alone to with your condition. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the services needed may be provided 
safely in a lower level of care.  
 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.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a ventilator is medically necessary. The Plan 
denied your request. The Plan says a ventilator is not covered for therapy that could be delivered by BiPAP. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 pre-approve a ventilator. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized with acute respiratory failure, and arterial blood gas (ABG) 
was consistent with acute on chronic hypercarbic respiratory failure. The enrollee's body mass index (BMI) is 
80, and the primary diagnosis is obesity hypoventilation syndrome. COPD is mentioned in the record on 
occasion, but there is no evidence to support this diagnosis. There is no diagnosis of thoracic restrictive disease 
or neuromuscular disease. The ventilator is ordered in the average volume assured pressure support (AVAPS) 
mode, which can be provided with BiPAP. There is no evidence to indicate the enrollee would require 
pressures or flow rates in excess of that provided with BiPAP. The records do not indicate that BiPAP, with or 
without AVAPS, has been tried and failed as an outpatient. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 will continue losing strength in your muscle. 
The Plan denied your request. The Plan says you do not meet the 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 you do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee has metastatic disease and needs treatment 
as soon as possible. The Plan denied your request. The Plan says it has not been shown that the enrollee's 
cancer type responds well to this treatment  
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has newly diagnosed prostate cancer and therefore would not have progression. It appears 
that this enrollee is getting his prostate/pelvis treated elsewhere. It is unclear why the regional nodal sites could 
not be included in the treatment field. A fairly accepted standard of care is to treat the regional nodes 
concurrently with the prostate cancer, and there are some data that treating more comprehensive nodal 
radiation. There is no compelling reason why SBRT (with potential risks) would be needed over simply 
including the nodal region in the definitive prostate field. The case records do not justify the need and the 
consult note simply states that they will use their new MR-LINAC to treat the enrollee without justifying why. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT).