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. The Plan denied your request. The Plan says the enrollee's 
information does not meet all of the requirements. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) coronary calcium score 
evaluation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CCTA with coronary calcium scoring is covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have excess 
lipids/fat in the blood (hyperlipidemia) and no active symptoms. YOu are on a Statin medication and would not 
benefit from a CT coronary calcium scoring evaluation. The requested test is used for individuals with a 
moderate 10 years risk for hardening of the arteries (atherosclerosis) who wish to decide about starting a 
Statin. The services are therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a computed tomography (CT) coronary calcium score evaluation.
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. The Plan denied your request. The Plan says the records do not 
show the need for an intense therapy team and physician 3 times a week. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and paclitaxel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says services associated with clinical trials are covered by Original Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare pays for the routine costs of qualifying 
clinical trials. 
 
We looked at the file and Medicare rules. The requested services are part of a clinical trial. Coverage for these 
services is from Original Medicare, not the Plan. Therefore, we decided that the Plan does not have to pre-
approve Keytruda and paclitaxel.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health physical therapy visits. 
 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 necessary. Our physician reviewer found the documentation does not 
support that you require additional skilled rehabilitation services in the home to provide treatment that is 
medically necessary. You do not require additional skilled rehabilitation services in the home to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health physical therapy visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on January 22, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99284 is included in the global surgery 
payment for procedure code 43762 provided on January 22, 2023. Separate payment cannot be made for 
procedure code 99284. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99284 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99284 provided on January 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the ventilator. Our physician reviewer 
found this enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. There is no documentation that this has been tried and 
failed as an outpatient. 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 25, 2021, to 
May 2, 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 this 
should be paid at the original DRG. The Plan denied your request. The Plan says the original DRG is not 
supported by the records. 
 
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 principal diagnosis code A40.3, defined as Sepsis 
due to Streptococcus pneumoniae, and secondary diagnosis code G92, defined as toxic encephalopathy. 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 documentation does not support the reported diagnosis codes. Our 
physician reviewer found the enrollee presented with weakness, dizziness and a fall. She subsequently spiked a 
fever and was found to have pneumonia. The enrollees blood cultures turned positive, resulting in a longer 
course of antibiotic treatment. There is no evidence of hypotension, hypoperfusion or organ dysfunction. The 
billed diagnoses are 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 April 25, 2021, to May 2, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography 
with contrast administration, including post-processing of parametric maps with determination of cerebral 
blood flow, cerebral blood volume, and mean transit time (0042T) provided on November 25, 2022.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says a covered diagnosis has not been billed for this service. 
 
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 service. Our physician reviewer found 
the review has determined that none of the diagnosis codes listed were valid diagnoses to indicate the cerebral 
perfusion analysis using computed tomography with contrast administration, including post-processing of 
parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 
(0042T) provided on November 25, 2022. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the cerebral perfusion analysis using computed tomography with contrast administration, 
including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood 
volume, and mean transit time (0042T) provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia to be used during lumbar epidural steroid 
injections. 
 
You asked the Plan to pre-approve anesthesia services. You say that deep sedation is needed to get the 
approved procedure completed. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that sedation during epidural steroid injections is not 
considered medically necessary unless there are exceptional and unique circumstances which show a need for 
the specific patient.  
 
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 anesthesia services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation 
clearly establishing why sedation is being ordered along with the epidural steroid injection. According to the 
primary care physician's note, the enrollee has sleep apnea, chronic obstructive pulmonary disease (COPD), 
and chronic respiratory failure. The enrollee is only on oxygen 2 liters via nasal canula at night. The enrollee is 
not on continuous oxygen. The records do not document an exception or unique case that clearly establishes the 
need for such sedation in this specific patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve anesthesia to be used during lumbar epidural steroid injections.
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. The Plan denied your request. The Plan says the enrollee's 
information does not meet all the requirements. 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 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 three (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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminectomy (0275T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says percutaneous laminectomy is considered experimental and investigational. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the percutaneous laminectomy decompression is experimental. More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous laminectomy (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device at the in-network benefit 
level. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record does not support the enrollee requires the device to manage activities of 
daily living (ADLs) nor does the evidence provided show the device is appropriate for the enrollee's condition. Spasticity impairs the response to the arm. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device at the in-network benefit level.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pancreatic surgery with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve pancreatic surgery with an OON provider. You say that the OON provider is 
able to see the enrollee within a week. The appellant says that the network provider they have been referred to 
is unable to perform the surgery in an appropriate timeframe. The Plan denied your request. The Plan says the 
surgery can be performed in-network in a reasonable timeframe that will not impact the enrollee's cancer stage 
or survival. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 pancreatic surgery with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the enrollee is newly diagnosed with pancreatic cancer. Expert surgery is available within the 
Plan's network within a reasonable timeframe. The request is for the convenience of the patient. It is not 
reasonable or medically necessary to receive care OON. It is medically reasonable for the enrollee to wait until 
the network provider is available in June or July of 2023, and there is no significant medical benefit to 
receiving the surgery sooner. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pancreatic surgery with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pancreatic surgery with an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is necessary. The Plan denied your 
request. The Plan says durable medical equipment (DME) supplies are limited to equipment and devices which 
do not duplicate the function of another piece of equipment or device covered 
by the Health Plan and are appropriate for use in the home. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the ventilator have not been met. Review of the documentation 
shows that the enrollee already has a non-invasive ventilator and a portable oxygen generator at home. This 
was also verified with the DME provider that the enrollee was already issued a E0466  non invasive home 
ventilator system on December 2022 with an approved authorization. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).