Persius/hicric huggingface dataset:
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 enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are network providers who are taking new patients and can get the 
enrollee in within a week. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97610-XU rendered on April 28, 2023. 
 
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 97610-XU 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 97610 is ""Low frequency, non-contact, non-thermal 
ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing 
care, per day." 
 
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 medical records provided 
indicate procedure 97605 was also performed on April 28, 2023.  CPT 97610 has a bundled relationship with 
CPT 97605. The guideline does allow for the use of a modifier to unbundle this relationship, providing the 
medical records support the use of an appropriate modifier. In this case, the medical records provided do not 
support that CPT 97610 was performed as a distinct procedure, independent of procedure 97605; therefore, it is 
not appropriate to use an XU modifier and 97610 is not eligible for reimbursement. 
 
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 procedure code 97610-XU rendered on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve chiropractic services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from August 17, 2023, to October 5, 
2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan follows Medicare rules. The rules state that home health services under a plan of care are paid based 
on a 30-day period of care. The rules say that when periods of care are created from a notice of admission, the 
common working file (CWF) calculates a period end date that does not exceed the start date plus 29 days. 
 
The file shows that the start of care date is August 17, 2023. The claim dates do not exceed the start date plus 
29 days, which would correctly be September 15, 2023. Therefore, we decided that the Plan has to pay for the 
home health services provided from August 17, 2023, to October 5, 2023.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to inpatient rehabilitation is medically 
necessary. The Plan denied your request. The Plan says admission to inpatient rehabilitation 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 that in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement; however, the 
documentation doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  The enrollee can receive further services 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: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy (PBT). 
 
You asked the Plan to pre-approve PBT. You say that the services are necessary. The Plan denied your request. 
The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for this the case file does document need, using quantifiable dosimetric measures, showing an 
IMRT plan that they consider unacceptable. This is challenging as the non-proton based plan meets NCCN 
criteria though the preferred constraint of heart V30 <20% is barely met, and the proton plan markedly reduces 
the cardiac exposure. As such, proton therapy would be considered to be furnished in accordance with accepted 
standards 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 PBT have been met. Therefore, we decided that the Plan has to pre-approve 
proton beam therapy (PBT).  
 
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 pay for the SNF care provided from June 30, 2023, to July 23, 2023, and from July 28, 2023, to July 29, 2023.

You asked the Plan to pay for SNF care. You say that the SNF care was medically necessary. The Plan denied your request. The Plan says there were no daily skilled services needed from June 30, 2023, to July 23, 2023, and from July 28, 2023, to July 29, 2023.

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 pay for 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 did not require the level of observation and treatment provided in terms of physician oversight and skilled nursing care. The enrollee was tolerating oral medications. They were noted to be alert and forgetful at times. Their vital signs were stable. They were noted to have scalp itch but no significant changes in their baseline medical conditions. They did not require daily skilled nursing services, including complex wound management, tracheostomy care, bowel and bladder training and tube feeding, or administration of intravenous medications. They were requiring primarily contact guard assistance and supervision for mobility and performing daily activities. They had not had a significant decline in their level of mobility and function and did not require the intensity of therapy services provided in a skilled nursing facility setting. Therefore, the skilled nursing facility care from June 30, 2023, to July 23, 2023, and from July 28, 2023, to July 29, 2023, was 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the SNF care provided from June 30, 2023, to July 23, 2023, and from July 28, 2023, to July 29, 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 you have significant decline in bodily strength 
needing to continue to receive at least three hours of physical therapy per day at an inpatient rehabilitation 
facility The Plan denied your request. The Plan says your condition does not meet all the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at 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 do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement; however, the documentation does not support that 
you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that 
you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. 
You can receive further services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 
3, 2023, to August 23, 2023. 
 
You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act.  The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay.  
 
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 pay for the 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from August 3, 2023, to August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton beam therapy. Our reviewer says 
that proton beam therapy Our physician reviewer found the enrollee specific DVH Dose Statistics for Photon 
using 3D technique (not Intensity-modulated radiation therapy (IMRT)/Rapid Arc) versus Proton plan is not 
submitted. There is no level I evidence that proton beam therapy (PBT) in this enrollee provides a superior 
outcome and/or less toxicities, including heart toxicities, compared to photon using standard 3D techniques/tangents +/- boost (if indicated) using either photon or electron. Medical records do not show that 
the enrollee is enrolled in a clinical trial. Medical records state that the enrollee is eligible in the REG-001 trial, 
but the proof/verification of enrollment in a clinical trial is not provided. Therefore, proton beam therapy (PBT) 
is not medically necessary in this 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has a rare tumor called Leiomyosarcoma 
and there is no other treatment. The Plan denied your request. The Plan says the use of this drug/regimen is not 
reasonable and 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 the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
metastatic leiomyosarcoma. Prior treatment has been doxorubicin. The tumor is PDl1 60%, microsatellite instability stable, and tumor mutation burden (TMB) low. The enrollee has been receiving pembrolizumab 
(Keytruda) from the manufacturer for compassionate use. This use is not FDA approved for the enrollee's 
diagnosis. The tumor is not TMB high or MSI high. The drug is not safe, effective, reasonable, or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this does not meet the criteria. The Plan denied 
your request. The Plan says the enrollee should be treated with IMRT. 
 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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was seen in consultation, and a course of consolidative radiotherapy with a palliative 
intent to a total dose of 35Gy in 10 fractions to left upper lobe lung mass was recommended using intensity 
modulated radiation therapy/volumetric modulated arc therapy (IMRT/VMAT) technique to prevent further 
obstruction. The IMRT/VMAT plan can provide some dosimetry advantage in this case which can potentially 
result in improved acute and sub-acute toxicities. However, the 3D plan meets the constraints recommended by 
QUANTEC. There is no level I evidence that IMRT/VMAT plan in this patient provides a superior outcome 
compared to 3D plan. There is no evidence that IMRT/VMAT can deliver tumoricidal doses of radiation but 
3D plan cannot. Therefore, IMRT/VMAT is not medically necessary in this case. 3D plan in this case is safe 
and effective. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity modulated radiation therapy (IMRT).