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 member's medical management and rehabilitation 
needs require an IRF admission and close physician supervision. 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 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: 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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 was admitted with adynamic ileus and osteomyelitis of the lumbar spine.  
The record indicates that the enrollee is improving but still require acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 99292 billed for March 22, 2021. 
 
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 procedure codes 99291 and 99292 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is critical care, 
evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List 
separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, there is no 
documentation of a critical care visit for 30-74 minutes to support code 99291. Given that the primary procedure code is not covered, add-on code 99292 is also not supported. 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 pay for procedure codes 99291 and 99292 billed for March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 4, 2022.
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 been hospitalized five times in the 
last three months, and will need aggressive rehabilitation to prevent further hospital readmissions. You also say 
the enrollee is physically very weak, and needs aggressive physical therapy. The Plan denied your request. The 
Plan says the Medicare criteria for medical necessity has not been met. 
 
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, rehabilitation, and medical, needs (no 
combined complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary 
approach to rehabilitative care. Our reviewer also found that while the enrollee may benefit from physical 
therapy, and occupational therapy, their rehabilitation needs can be provided in a lower intensity and alternate 
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 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 supartz or visco-3 (J7321). 
 
You asked the Plan to pre-approve supartz or visco-3. You say that cortisone is not recommended for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not completed at least three months of 
physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 supartz or visco-3. Our reviewer says 
that the requested drug is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the knee. The record does not indicate that the enrollee has failed a 
trial of conservative non-pharmacologic treatment. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer 
found that the requested drug is not medically reasonable or 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 supartz or visco-3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve supartz or visco-3 (J7321).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and 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 Imfinzi. Our reviewer says that Imfinzi 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Imfinzi (J9173) is not FDA-approved for the enrollees diagnosis. The enrollee has completed 1 year of therapy 
with durvalumab. Our reviewer found that the use is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. 
Our physician reviewer also found that the use is not listed as not indicated, not supported or not recommended 
in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from April 24, 
2023, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the enrollee no longer meets the conditions 
for coverage for an inpatient psychiatric admission. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric services. 
Our reviewer says that the Plan's denial of continued services appears appropriate in this case. Our physician 
reviewer found that it appears the enrollee has reached the maximum benefit from her inpatient psychiatric 
stay. The enrollee is noted to be in no psychiatric distress and is eating and sleeping adequately. She is 
complaint with her medications. The progress notes do not indicate that the enrollee has been aggressive with 
peers or staff on the unit or has had any recent attempt to harm herself during the disputed period. As of the last 
covered day, there is no indication in the available medical records that the enrollees psychiatric symptoms 
could not be managed on a less restrictive basis. As of the last covered day the enrollee did not express any 
active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee was not 
exhibiting any other significant symptoms such as mania and had no acute psychiatric issues that would require 
continued inpatient care beyond April 24, 2023. The enrollee has chronic symptoms, but the available medical 
records do not support that continued inpatient care will change these symptoms or the enrollees current 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services from April 24, 
2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Afirma thyroid genomic testing (81546) provided on 
September 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that a prior authorization should not be required. The 
Plan denied your request. The Plan says the records do not support that this testing is medically necessary. 
 
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 at issue in this case is not a network provider with the Plan. 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 genetic testing. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found per the reviewed 
documentation, a 1.4 cm thyroid nodule was biopsied using fine needle technique. The available records report 
that the cytopathology shows that no concerning features are identified in sample that is limited by obscuring 
blood and scant cellularity. In this case, the Afirma results for Nodule A (upper right) are an outside indication 
(OI) due to lack of an indeterminant cytopathology report. The review has determined that the items/services at 
issue in this case are not medically reasonable or 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 the genetic testing have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for the 
genetic testing. Therefore, we decided that the Plan does not have to pay for the Afirma thyroid genomic 
testing (81546) provided on September 10, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Retacrit. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found provided records do not document a 
hemoglobin of less than 10 g/dL. Provided records do not document B12 and folate deficiency have been 
excluded. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. The Plan denied your request. The Plan says the requested SPRINT 
neurostimulator, continues to be studied to determine safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SPRINT PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Medicare says for a peripheral nerve stimulator to be medically necessary the patient 
must first undergo a successful trial stimulation. The requested SPRINT PNS system is a temporary (for up to 60 days) device with no trial stimulation. This enrollee has not had a trial stimulation. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 the SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) system (64555).
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 member's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the member's status does not meet medical 
necessity, severity, or intensity criteria 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provided is not 
enrollee in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on July 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on March 15, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the services reached the benefit maximum for this time period or occurrence 
has been reached. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Medicare does not cover refractive procedures even 
when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested ventilator is not medically reasonable and necessary. Our physician reviewer found that the provided records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The home ventilator is being requested for use in targeted tidal volume - volume assured 
pressure support (TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with 
average volume assured pressure support (AVAPS) and a back-up rate. The provided records do not document 
trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.