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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has made progress and would benefit 
from increased therapy intensity at an IRF level of care in order to return to their prior level of function. The 
Plan denied your request. The Plan says the enrollee's condition does not meet Medicare guidelines for services 
in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment (E0188, E0935) provided on January 9, 
2023 to January 20, 2023. 
 
You asked the Plan to pay for the items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the codes billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The records do not 
included a proof of delivery or patient receipt for these items. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for medical equipment (E0188, E0935) provided on January 9, 2023 to January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 1, 2023, billed with 
procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The billed service is a non-covered service 
and is not payable. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on May 1, 2023, billed with procedure codes 96365-59, 96366-59, and 96521.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 1, 2023, to 
March 30, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted. The Plan denied 
your request. The Plan says the NOA was not received. As such, this final claim was correctly denied. The Plan 
says that although you claim that the NOA was submitted, none has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from March 1, 
2023, to March 30, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic radiosurgery (SRS) treatment (77372). 
 
You asked the Plan to pre-approve SRS treatment. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that there is no good evidence SRS is the best or a 
good treatment for the enrollee's condition. 
 
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 SRS treatment. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the American Society for Radiation Oncology (ASTRO) model policy for radiosurgery lists no 
restrictions on SRS based upon primary cancer type or number of lesions, or prior treatment (i.e., having 
undergone prior SRS) but rather emphasizes the need of SRS in enrollees with good performance status, and 
who are expected to have a reasonably long-life expectancy warranting treatment. The National 
Comprehensive Cancer Network (NCCN) guidelines for brain metastases explicitly state: The NCCN Panel 
decided that SRS may be used for selected enrollees with a small number of brain metastases based on 
available data, pending outcomes of the ongoing trials. as well as Brain metastases have conventionally been 
treated with whole brain radiation therapy (WBRT); however, selected enrollees with a small number of 
metastases may be appropriately treated with stereotactic radiotherapy (SRT)/radiosurgery (SRS). Given that 
the treatment of one small brain metastasis with SRS in an enrollee with small cell lung cancer with good 
performance status is in accordance with accepted standard practice (First-line Radiosurgery for Small-Cell 
Lung Cancer (FIRE-SCLC) conclusions and NCCN guidelines), the reviewer believes that the treatment can be 
considered within accordance of accepted standards of medical practice and therefore 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 SRS treatment have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic radiosurgery (SRS) treatment (77372).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 10, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on April 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain single-photon emission computed tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a brain SPECT scan. 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 brain SPECT scan. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that use of the brain SPECT scanning has been shown in controlled studies in a CMS-approved journal to result in long term health benefits in patients with dementia. Although some studies have 
shown some potential diagnostic utility of SPECT scanning in dementia, the modality remains under 
investigation. 
 
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 brain SPECT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a brain single-photon emission computed tomography (SPECT) scan (78803).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for cognitive therapy (codes 97129 and 97130) provided from  
November 16, 2022, to January 25, 2023. 
 
You asked the Plan to pay for cognitive therapy. You say that the services were medically necessary The Plan 
denied your request. The Plan says that these codes represent physical therapy and a speech therapist cannot 
bill for physical therapy. 
 
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 Plans rationale that the billed codes are for physical therapy only is not 
valid. Specifically, the Plan has not provided claims with evidence of which modifiers were used to 
substantiate the denial. Therefore, we decided that the Plan has to pay for cognitive therapy (codes 97129 and 
97130) provided from November 16, 2022, to January 25, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the enrollee needs treatment, and you feel everything 
was not looked over because you submitted all the required information that was needed. The Plan denied your 
request. The Plan says the use of Leqembi in this enrollee is not reasonable and necessary. 
 The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid 
that are approved by the FDA for the treatment of AD based upon evidence of efficacy from a change in a 
surrogate endpoint considered as reasonably likely to predict clinical benefit may be covered in a randomized 
controlled trial conducted under an IND application. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Leqembi (J0174).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 7, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are 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. The rules also say that the physician must 
clearly document, in the medical record, his or her intent that the test be performed. 
 We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the records 
do not contain an order for the specific tests provided in this case. The documentation also does not contain 
medical records showing the ordering physicians intent that this testing be performed. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 6, 2023, to 
March 29, 2023. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 6, 2023. The NOA was not received by the Plan until April 6, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
March 6, 2023, to March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic respiratory failure 
secondary to COPD and obesity hypoventilation syndrome. The device is medically necessary. The Plan denied 
your request. The Plan says the request is not medically necessary because the records show that the ordered 
setting for the ventilator is going to be used only in a bi-level pressure mode. 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently admitted to the hospital and treated for chronic respiratory failure with BIPAP therapy. She had 
adequate response and tolerated BIPAP with average volume-assured pressure support (AVAPS).  Hence, the 
enrollee does not have failure of BIPAP therapy and does not require a home ventilator per documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on April 17, 2023, billed with 
procedure code 76882-26-LT. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right, or is bilateral.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. Code 76882-26-LT was inappropriately billed 
with diagnosis code R10.30 as there is a more specific diagnosis for this service when appended with an LT 
(left) modifier. Therefore, we decided that the Plan does not have to pay for testing services provided on April 
17, 2023, billed with procedure code 76882-26-LT.
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 meets the Medicare criteria for IRF care 
and will benefit from IRF services that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  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: 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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be stable on current treatment regimen 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 enrollee does not require services at the LTACH 
that are not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.