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

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 pre-approve a kyphoplasty. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documented trial of bracing. Additional conservative measures are needed to demonstrate 
the medical necessity of the requested procedure. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that serum iron studies are covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The file does not contain any medical records documenting of 
medical necessity for the testing. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health services June 12, 2023, and 
forward. 
 
You asked the Plan to pre-approve inpatient behavioral health services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient behavioral health services. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric 
hospitalization on May 24, 2023, with Major Depressive Disorder, Recurrent, Severe without Psychotic 
Features. This enrollee presented with suicidal ideation and a plan to overdose on Seroquel. This enrollee did 
not require inpatient mental health treatment beyond the dates in question as noted above as he was not a 
danger to himself or others and did not have any delusions, auditory or visual hallucinations. Therefore, the 
enrollee does not meet criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of June 12, 2023, and forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health services June 12, 2023, and forward.
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 need the rehab to return to baseline level of 
function. The Plan denied your request. The Plan says the 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 complexity of your nursing, medical, and rehabilitation needs does 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio. 
 
You asked the Plan to pre-approve Zarxio. 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 FDA-
approved 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 Zarxio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Zarxio is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix 
for list of CMS-approved journals). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zarxio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 6, 2022 to 
September 9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says secondary diagnosis code N17.0 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee presented with weakness and found to have dehydration and a 
urinary tract infection, in the setting of a colostomy and dementia. The enrollee was treated with IV fluids and 
antibiotics, resulting in improvement.  There is no evidence that the enrollee had intrinsic renal injury. The 
decrease in the enrollees renal function was attributed to dehydration. As such, a diagnosis of N17.0 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 6, 2022 to September 9, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have a lot of 
upcoming doctor's appointments and labs. The Plan denied your request. The Plan says the requested services 
exceed your benefit limit. 
 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 24 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 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 (13 units) billed for date of service 
December 27, 2022. 
 
You asked the Plan to pay for 13 units of procedure code 87798. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this code is not supported 
in the medical record for the number of units billed. Only 10 units are supported in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 13 units of procedure code 87798 Our 
reviewer says that this service is not supported for the 13 units reported. Our physician reviewer found that 
given the testing approved by the health plan under procedure codes 87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87640, 87651, U0005 and U0004, and provided documentation supports billing of CPT 87633, 
only 10 units of CPT 87798 (infectious agent detection nucleic acid, amplified probe technique, each organism) 
remain supported. The records do not support 13 units of CPT 87798.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 13 units of procedure code 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 87798 (13 units) billed for date of service December 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical therapy, by intra-arterial particulate 
administration (79445). 
 
You asked the Plan to pre-approve radioembolization. You say that all of the necessary processes for the 
embolization have been approved but not the actual nuclear medicine that is being injected. you need this 
service approved. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan.  There is not enough evidence that this is useful for your condition. 
 
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 radioembolization. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found radioembolization in and of itself is not an experimental technique and is FDA 
approved for primary HCC and for liver metastases from colorectal cancer. Its application in the treatment of 
liver malignancies from many other primary sites (i.e., neuroendcrine cancer, breast cancer) is also supported 
by the literature. For renal cell carcinoma, there are fewer published studies of radioembolization. For bulky 
liver disease, with no other therapeutic options, who has previously undergone systemic therapy, the reviewer 
does think that the treatment with Y90 radioembolization can be considered medically necessary. For you, 
however, there is evidence of widespread disease progression, and you were offered a next line of systemic 
therapy (Everolimus and Lenvatinib). The case records do not adequately support the need for 
radioembolization in this setting. While quality of life can be potentially be improved with liver-directed 
therapy, the records indicate that you tolerated it poorly previously and the benefit for you with widespread 
progression is not established. The decision is unfavorable as radioembolization is not standard of care in the 
setting of widespread progression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radioembolization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiopharmaceutical therapy, by intra-arterial particulate administration (79445).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on January 14, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the test panel cannot 
be unbundled. 
 
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 argues that the test panel cannot be unbundled. However, the Plan has 
not provided a Medicare rule showing that the testing in this case cannot be billed with multiple codes and 
multiple units of service. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the testing provided on January 14, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve home health visits. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
home health visits to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need rides to 
appointments due to medical issues. The Plan denied your request. The Plan says the requested number of trips 
exceeds your transportation benefit. 
 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 24 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 additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2021 to 
October 18, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was not billed correctly. The Plan denied your request. The Plan says the principal diagnosis code was 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee presented with altered mental status and wound issues following a thrombotic 
microangiopathy (TMA). The enrollee received antibiotics and underwent a below knee amputation (BKA). 
There is no evidence of hypotension, hypoperfusion or organ failure.  As such, the billing of A41.9 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 4, 2021 to October 18, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Life2000 system is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep as an outpatient. The Life2000 system is not a true ventilator 
because it is not capable of providing full ventilatory support. It is intended to be used during activity, and there 
is inadequate evidence that it is beneficial in the treatment of any chronic lung disease. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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 (E0466).