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

 
We decided that the Plan has to pre-approve inpatient services. 
 
You asked the Plan to pre-approve inpatient services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
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 inpatient services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was transferred from another facility for evaluation of renal masses, hematuria, 
pancreatic lesion, and hematuria. The enrollee was evaluated by Urology, Nephrology, Oncology, 
Interventional radiology. and Orthopedics. The enrollee underwent full evaluations including radiological 
studies and biopsies. The requested inpatient services were medically necessary and indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have been met. Therefore, we decided that the Plan has to pre-
approve inpatient services.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x7). 
 You asked the Plan to pre-approve home health services. You say that this is medically 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 reasonable and necessary. Our physician reviewer found documentation 
states that enrollee's lab draws are required weekly but then under goals states that labs are to be drawn every 
three months regarding Procrit injections and does not specify any other conditions in which the enrollee would 
require weekly home health skilled nursing visits. The records do not show that 7 additional home health 
skilled nursing visits would be required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's 
condition and/or prevent deterioration. 
 
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 home health skilled nursing (G0299 x7).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service March 6, 2023, 
to March 22, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's 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. 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 for date of service March 
6, 2023, to March 22, 2023.
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 lacking strength and needs 
rehabilitation to help assist with current condition. 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 you do 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 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. 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0482) provided on August 18, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says that this claim is denied. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for drug testing (G0482) provided on August 
18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve an external upper limb tremor stimulator. You say that you are requesting 
reconsideration that the Plan make an exception to medical coverage for this device and base the decision on 
the enrollee's specific needs and the proven safety and efficacy of the technology. The Plan denied your 
request. The Plan says the request is not medically necessary because based on the medical literature, this 
device is considered experimental or investigational and has not been proven to be beneficial for the control of 
tremor. 
 
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 an external upper limb tremor 
stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a diagnosis of essential tremor. It is 
documented that the enrollee could not tolerate primidone, did not like the side effects of topiramate, got dizzy 
on gabapentin, and metoprolol did not impact his tremors. There is insufficient evidence that the requested 
nerve stimulator device is medically reasonable and necessary for the enrollee in this case. It has not been 
demonstrated that the requested device provides persistent benefit and is at least as beneficial as existing and 
medically appropriate alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external upper limb tremor stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral 
nerves of the wrist (K1018).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat genicular radiofrequency ablation (RFA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found genicular RFA is subject of several 
ongoing clinical trials to determine its role in the treatment of knee arthritis. It is considered experimental in 
nature and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat genicular radiofrequency ablation (RFA).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment provided on January 02, 
2023. 
 
You asked the Plan to pay for the medication assisted treatment. You say that prior authorization is not needed 
for this service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the medication assisted 
treatment provided on January 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy pumps (NPWT). 
 
You asked the Plan to pre-approve negative pressure wound therapy pumps. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the rules state that NPWT systems, pumps and their 
associated supplies, that have not been specifically designated as being qualified to use Healthcare Common 
Procedure Coding System (HCPCS) codes E2402 via written instructions from the Pricing, Data Analysis and 
Coding (PDAC) Contractor 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 negative pressure wound therapy 
pumps. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
record of the provider discussing the change with the home health nurse, so the supervision of the dressing 
changes by your medical provider has not been documented.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of negative pressure wound therapy pumps have not been met. Therefore, we 
decided that the Plan does not have to pre-approve negative pressure wound therapy pumps (NPWT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home 
without adequate therapy and 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 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 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 has fallen multiple times and requires an 
IRF admission that can help with safety and security. The Plan denied your request. The Plan says the enrollee 
does not meet all the requirements for an IRF 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798, 
billed for date of service May 23, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87641, 87653, and 87798, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87801. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 
87798, billed for date of service May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a little more therapy to heal 
properly. 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 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 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 based on the enrollee's current condition and 
functional deficits, as well as their multiple comorbidities, you have determined that they meet full inpatient 
acute rehabilitation criteria. The Plan denied your request. The Plan says an admission to an IRF is not 
reasonable and 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).  
You asked the Plan to pre-approve Injectafer. You say that Injectafer is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Injectafer have not been met. 
 
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 Injectafer. Our reviewer says that 
treatment with Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of any two of drugs Ferrlecit, Feraheme or Venofer they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).