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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is a great option to 
continue hospital-level care in a longer-term setting before discharge to a lower level of care. The Plan denied 
your request. The Plan says the request is not 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure injection. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sure injection.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has post-menopausal osteoporosis. The documentation does not support that the enrollee has 
tried and failed an oral bisphosphonate (such as alendronate, risedronate, or ibandronate) or zoledronic acid. 
The documentation does not support that an oral bisphosphonate (such as alendronate, risedronate, or 
ibandronate) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 inpatient rehabilitation to get stronger. The 
Plan denied your request. The Plan says your records do not show that your rehabilitation needs are complex. 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block 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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are 
considered experimental/investigational in nature. The requested genicular nerve block is not reasonable or 
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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
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 complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require acute hospital admission. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99220) provided on August 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit".  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99220 is 
not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
comprehensive history and medical decision making of high complexity. 
 
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 services (99220) provided on August 30, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional two miles for a total of 52 miles for routine 
transportation. 
 
You asked the Plan to pre-approve an additional two miles. You say that you would like to visit an in network 
dental provider. You also say that you are concerned about pain and possible infection if you cannot see the 
dental provider. The Plan denied your request. The Plan says that additional miles are not covered. 
 
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. Review of the file shows that you are requesting additional miles to see a dental 
provider. The Plan did not include the address of the dental provider or of your home address to Maximus to 
review for possibly different directions of less miles to get to the destination. Maximus requested the address of 
the requested provider on two different occasions, in which was not responded to once, and another time the 
Plan provided the address of the transportation company. Without this address information, we are unable to 
determine if 52 miles are really needed for you to see the requested dentist. Therefore, the Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pre-approve an additional two miles for a 
total of 52 miles for routine transportation.  
 
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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 27337. We decided that the Plan does not have to pay for 99231.  
 
You asked the Plan to pay for the services (27337, 99231) provided on June 11, 2022, and June 12, 2022.. You 
say that  The Plan says that  
 
We decided that the Plan has to pay for code 27337 billed on June 11, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 27337 is Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater" 
 
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 for code 27337. Our reviewer says that the use of code 27337 is 
supported by the records provided. Our reviewer found that in this case, 4 cm was documented in the operative 
report, and would be reported with CPT 27337. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27337 have been met. Therefore, we decided that the Plan has to pay for 
code 27337 billed on June 11, 2022.  
 
We also decided that the Plan does not have to pay for code 99231 billed on June 12, 2022. 
 
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 the requested service (99231) is included in the global 
surgery payment for the procedure (20103) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of code 99231 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99231 billed on June 12, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you suffered a heart attack and the IRF admission is 
necessary for you to regain maximum function. The Plan denied your request. The Plan says the IRF services 
requested 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may benefit from physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you 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 an 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 enrollee is susceptible to falls, and needs 
monitored care for better treatment. The Plan denied your request. The Plan says the enrollee's records do not 
show the need for an intensive team for 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF testing (81455) provided on November 25, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test does not meet the criteria for coverage. 
 
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 pay for Tempus xF testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has metastatic prostate cancer, but additional clinical information is not 
provided. Per the National Comprehensive Cancer Network Guidelines, the panel strongly recommends a 
metastatic biopsy for histologic and molecular evaluation. When unsafe or unfeasible, plasma circulating tumor 
(ctDNA) assay is an option, preferably collected during biochemical (PSA) and/or radiographic progression in 
order to maximize diagnostic yield. There is no information regarding evaluation of tissue next generation 
sequencing (NGS) or if prior testing. This service was not reasonable or medically necessary in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Tempus xF testing (81455) provided on November 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the platelet rich plasma (PRP) injection and fat grafting 
provided on April 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that PRP injections and fat grafting are purely experimental at this time. More research is needed for 
these services. 
 
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 the platelet rich plasma (PRP) injection and fat grafting provided on April 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening provided on September 9, 2022.  
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet the applicable criteria.  
 
We looked at the file and Medicare rules. The enrollee in this case does not meet the coverage criteria for the 
provided ultrasound screening. Based on this information, we decided that Medicare rules for coverage of the 
screening have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound 
screening provided on September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's ongoing medical care 
warrants a LTACH level of care. The Plan denied your request. The Plan says when the enrollee is ready to 
leave the hospital, they can safely receive this care in another setting, such as a skilled nursing recovery and 
rehabilitation facility. 
 
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 improving gradually, but is not yet stable, 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 a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.