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 was completely independent prior to this 
hospitalization, and the goal is for the enrollee to return to that independent lifestyle. The Plan denied your 
request. The Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. At the current 
functional level, the enrollee needs routine physical and occupational therapy and does not need intensive 
therapies consisting of at least three hours of therapy per day at least five days per week with a 
multidisciplinary approach in an IRF. The enrollees rehabilitation needs can be safely provided in an alternate 
and low intensity setting such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, 83789-59 and G0480) 
provided June 29, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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, we have confirmed that code 83789 is a column II code to column I codes 80307 and G0480; 
however, 83789 was billed with a modifier.  
 
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 found for code 80307, the 
documentation submitted was reviewed and does not meet criteria. The physician order does not include 
sufficient documentation to verify tests ordered. The custom panel was ordered; however, 1-7 drug classes 
cannot be verified. 
 
For code 83789, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with CPT 80307; 
however, medical record supports urine drug test which includes specimen validity. Therefore, this procedure 
resulted in unbundled service. For code G0480, the documentation submitted was reviewed and does not meet 
criteria. The physician order does not include sufficient documentation to verify tests ordered. The custom 
panel was ordered; however, 1-7 drug classes cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (80307, 83789-59 and G0480) provided June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is out-of-network and these services were available in-network. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the treating 
physician did not document, in any of the physician notes, on a form, or in an order than the enrollee was not 
stable for transfer on the dates of service. The documentation supports that the enrollee was stable for transfer 
to an in-network hospital on 11/3/2023 at 10:53. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient psychiatric care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs more time for physical therapy. 
You say the enrollee has had pneumonia which slowed down progress. The Plan denied your request. The Plan 
says continuation of SNF services is not medically necessary and does not meet Medicare guidelines. 
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine podiatry visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the documentation fails to indicate that additional routine podiatry visits are 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pre-approve the additional visits. Our 
reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician 
reviewer found that the medical documentation supports that this enrollee is suffering with thick painful toenails inhibiting normal comfortable ambulation. A diagnosis of onychomycosis was made from a clinical 
perspective. The enrollee is also noted to have diabetes. The physical examination reveals that pedal pulses are 
diminished but palpable. The medical documentation does not comment on other criteria that would allow for 
routine foot care. The medical documentation does not advise on a condition that results in a severe loss of 
circulation to the lower extremity. The medical documentation does not advise on the sensation of this patients 
legs or feet. There is no comment vibratory sensation, soft touch sensation, or protective sensation. There is no 
evidence of open lesions or infected ulcerations. Therefore, the need for additional visits has not been 
demonstrated. Therefore, we decided that the Plan does not have to pre-approve additional routine podiatry 
visits.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is medically necessary. 
 
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 is presently receiving appropriate services in the acute care setting. 
Records do not support the need to transfer from one acute hospital to another. Continued care in the short-term 
acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of breast cancer with metastases to bone. The documentation does not 
support that the enrollee has tried and failed intravenous pamidronate or zoledronic acid. The documentation 
does not support that intravenous pamidronate or zoledronic acid would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
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 is upset the appeal was denied as they 
were active and ready to participate in 3 hours of therapy. The Plan denied your request. The Plan says an IRF 
admission 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 the complexity of the enrollees 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 Yervoy and Nivolumab. 
 
You asked the Plan to pre-approve Yervoy and Nivolumab. You say that the requested Yervoy and Nivolumab 
is medically necessary. The Plan denied your request. The Plan says the requested Yervoy and Nivolumab is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Yervoy and Nivolumab. Our reviewer 
says that the requested Yervoy and Nivolumab is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of recurrent non-small cell carcinoma of the lung with ALK genomic tumor aberration and PDL1 positivity previously treated with cis/etoposide and radiation therapy.  The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were 
submitted for review.  The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Yervoy and Nivolumab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Nivolumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services in order to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the 
request 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0955, E0960, E1007, E1012, E1028, 
E2300, E2311, E2313, E2363, and E2377). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the requested wheelchair and accessories are medically necessary to meet the enrollee's current 
needs. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options available with a K0861 group 3 power wheelchair. The Plan also says that the expandable controller, 
harness and electronics are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found while the enrollee has a mobility deficit that impairs mobility related activities of 
daily living in the home the power seating system is not medically necessary. The enrollee does not use a 
ventilator attached to a wheelchair. Our reviewer found that the enrollee does not use intermittent 
catheterization, need a power seating system to manage spasticity, and is not at high risk for a pressure ulcer. 
Our physician reviewer found that as the enrollee does not have need for both power tilt and power recline, the 
request for the K0861 Group 3 power wheelchair is not reasonable and 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 a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power option (K0861) and additional items and accessories (codes E0955, E0960, 
E1007, E1012, E1028, E2300, E2311, E2313, E2363, and E2377).
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 currently meets acute inpatient 
rehabilitation hospital admission criteria under CMS guidelines. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee needs physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of 
their condition doesnt require an IRF stay and care can be provided in a lower level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. 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 follows Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
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 a heavy duty extra wide hospital bed. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for a 
heavy duty extra wide hospital bed (E0303) has not been met. The enrollee weighs 300 lbs. The criteria states 
that for the requested item the enrollee must meet one of the criteria for a fixed height hospital bed and the 
enrollee's weight must be more than 350 pounds but does not exceed 600 pounds. 
 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 heavy duty extra wide hospital bed have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).