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 you want to go to an IRF to return home safely and 
more independent. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
but continue skilled therapies as an outpatient or at a skilled nursing facility may be approved upon request.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was initially admitted to the hospital for 
respiratory failure, intubated for a while and also had a upper GI bleed with several post service complications. 
You also say that they are very debilitated due to laying in bed for so long. The Plan denied your request. The 
Plan says based on the available information, admission to IRF is not reasonable and necessary, as the 
enrollee's condition does not meet the Medicare rules.  
 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 
was admitted for aspiration pneumonia and gastrointestinal bleeding. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that there has been a rotation of doctors that ordered the 
inpatient rehabilitation to be expedited due to flu, throat cancer and falling twice. You also say that this request 
was instructed to have the enrollee admitted to rehabilitation as soon as possible. The Plan denied your request. 
The Plan says based on the available information, admission to IRF is not reasonable and necessary, as the 
enrollee's condition does not meet the Medicare rules.  
 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 enrolee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for falling after recent admission for a tib-fib fracture. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99232 billed for date of service January 3, 2023, and 
procedure code 99233 billed for date of service January 10, 2023. We decided that the Plan does not have to 
pay for procedure code 99232 billed for date of service January 5, 2023.  
 
You asked the Plan to pay for the evaluation and management services provided from January 2, 2023, to 
January 11, 2023. You say that no issues were identified for the codes. The Plan says that the documentation 
does not support the code. 
 
We decided that the Plan has to pay for procedure code 99232 billed for date of service January 3, 2023, 
and procedure code 99233 billed for date of service January 10, 2023.  
 
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 file shows that the services provided on January 3 and 10, 2023 were denied and appealed. The 
explanation of payments included in the case file does not provide a rationale why the services were originally 
denied. The Plan does not provide a rationale after appeal as to why these services continue to be denied. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Therefore, we decided that the Plan has to pay for procedure code 99232 billed 
for date of service January 3, 2023, and procedure code 99233 billed for date of service January 10, 2023.  
 
We also decided that the Plan does not have to pay for procedure code 99232 billed for date of service 
January 5, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99232 is not supported in the medical record. The records provided do not include 
services provided on the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99232 billed for date of service January 5, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy (45380, 45378) and esophagogastroduodenoscopy 
(43239, 43235). 
 
You asked the Plan to pre-approve a colonoscopy and esophagogastroduodenoscopy. You say that this is 
medically necessary. The Plan denied your request. The Plan says that your provider recommended iron studies 
with a plan for possible esophagogastroduodenoscopy and colonoscopy if these studies were indicative of 
ongoing iron deficiency anemia or gastrointestinal bleeding. There is no documentation of the results of the 
iron studies to confirm a diagnosis of unexplained iron deficiency anemia. 
 
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 a colonoscopy and 
esophagogastroduodenoscopy. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found documentation shows low ferritin and iron 
deficiency anemia, so meets criteria for upper endoscopy and colonoscopy. 
 
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 colonoscopy and esophagogastroduodenoscopy have been met. Therefore, we 
decided that the Plan has to pre-approve a colonoscopy (45380, 45378) and esophagogastroduodenoscopy 
(43239, 43235).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physical and occupational 
therapy. The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled 
therapies as an outpatient or home with home therapy.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a cardiology visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization 
was not obtained. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiology visit to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the enrollee needs for treatment. The Plan denied your 
request. The Plan says there is no record that shows the enrollee tried the preferred drug Byooviz and it hasn't 
worked.  
 
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 Eylea. Our reviewer says that the drug 
is not medically necessary. Our physician reviewer found there is no indication the Plan's required drug would 
be less effective and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, a laminectomy, 
facetectomy and foraminotomy, a lumbar arthrodesis, and an anterior interbody technique.  
 
You asked the Plan to pre-approve a percutaneous vertebral augmentation, a laminectomy, facetectomy and 
foraminotomy, a lumbar arthrodesis, and an anterior interbody technique. You say that the enrollee has L4-5 
foraminal stenosis and increase kyphosis from the compression fracture at T12 and L5 radiculopathy. The Plan 
denied your request. The Plan says a percutaneous vertebral augmentation, a laminectomy, facetectomy and 
foraminotomy, a lumbar arthrodesis, and an anterior interbody technique 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 a percutaneous vertebral augmentation, 
a laminectomy, facetectomy and foraminotomy, a lumbar arthrodesis, and an anterior interbody technique. Our 
reviewer says that a percutaneous vertebral augmentation, a laminectomy, facetectomy and foraminotomy, a 
lumbar arthrodesis, and an anterior interbody technique are not medically necessary. Our physician reviewer 
found that there is no documented spinal instability fracture or lesion, and spinal fusion not needed. 
 
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 percutaneous vertebral augmentation, a laminectomy, facetectomy and 
foraminotomy, a lumbar arthrodesis, and an anterior interbody technique have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, a laminectomy, 
facetectomy and foraminotomy, a lumbar arthrodesis, and an anterior interbody technique.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to meet 
diagnostic criteria for both AD and FTD. Rather the records provided for review only indicated a suspicion of 
AD. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee's carbon dioxide levels continue to 
rise. You say that the enrollee's life is in jeopardy due to not having the ventilator. You also say that the 
enrollee almost passed away twice due to levels going up over 700. The Plan denied your request. The Plan says noninvasive ventilators used solely as a respiratory assist device are considered not reasonable and 
necessary per Medicare Guidelines. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the provided records indicate 
diagnoses of chronic obstructive pulmonary disease (COPD), congestive heart failure, and obstructive sleep 
apnea. The enrollee was hospitalized recently with bilateral pneumonia. An arterial blood gas (ABG) was 
consistent with chronic carbon dioxide (CO2) retention. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. There are no pulmonary function tests to confirm airways obstruction and assess the 
severity. The enrollee initially deteriorated in the hospital with an increase in the partial pressure of carbon 
dioxide (PaCO2) to 113, but this decreased to 54 over approximately 1 day on bilevel positive airway pressure 
(BiPAP) 20/10. The hospital records indicate that the enrollee's deterioration was likely due to a combination of 
pneumonia and heart failure. The enrollee reportedly has a home BiPAP, but the settings are not provided and 
there is no compliance data. The records do not show that BiPAP with volume assurance during sleep as an 
outpatient has been trialed. Therefore, the reviewer found that the requested ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).