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 are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that he would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his functional 
status.  
 
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 surgical services provided on April 10, 2023, billed with 
codes 99308-25, 11043, and 17250-59. 
 
You asked the Plan to pay for the surgical services as billed. You say that the records support the need for these 
services, and the claim was coded correctly.  The Plan denied your request. The Plan says this was not coded 
correctly for services provided in the postoperative period of the surgery provided on April 4, 2023.  
 The Plan must follow Medicare rules. Medicare rules say that services provided during the postoperative period 
of a 10-day period minor surgery must be billed with modifiers -24 and/or -79 to identify that they are 
unrelated to the prior procedure. 
 
We looked at the file and Medicare rules. The same provider billed code 17000 on April 4, 2023. The 
postoperative period for this was 10 days. The services at issue were provided within that period, and the 
required global surgery modifiers were not reported. Based on this information, we decided that Medicare rules 
for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services provided on April 10, 2023, billed with codes 99308-25, 11043, and 
17250-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an infrared therapy device on March 22, 2023. 
 
You asked the Plan to pre-approve infrared therapy. You say that this was medically necessary. The Plan 
denied your request. The Plan says this service is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve use of an infrared therapy device on March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services rendered from November 19, 
2022, to November 21, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim are supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 100. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented to the emergency department (ED) status-post seizure, and described as being in a 
postictal state. The vitals were stable, however. The electrocardiogram showed a normal sinus rhythm. 
Hyponatremia was noted but was corrected with fluids. Mental status improved with treatment. The code 
I21.A1 (myocardial infarction type 2) was not sufficiently supported as the patient did not have symptoms 
suggestive of infarction and the elevated troponin was deemed as related to demand ischemia. Therefore, the 
DRG 101 would be more appropriate for this admission based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from November 19, 2022, to November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from December 28, 
2022, to December 31, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says the DRG 
is updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with flank pain with neutropenia in the setting of metastatic prostate cancer with 
lower urinary tract symptoms. He was started on fluids and antibiotics. The workup did not, however, reveal 
evidence of significant organ failure due to a dysregulated response to systemic infection as the bilirubin, Cr, 
platelets, blood pressure were normal. There was no documented low Glasgow Coma Scale (GCS) score, no 
significant oliguria, and no hypoxia. The Sepsis 3 criteria were not met. Therefore, the code, A41.9 (sepsis) is 
not sufficiently supported by the provided documentation for this admission. DRG 726 is supported for this 
admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from December 28, 2022, to December 31, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 25600 rendered on April 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code is not supported in the records submitted. 
 
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 25600 is "Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, 
includes closed treatment of fracture of ulnar styloid, when performed; without manipulation." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the x-rays showed a fracture. The 
right wrist was placed in a sugar tongue splint. Therefore, the documentation does support that CPT 25600: 
closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; without manipulation was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 25600 rendered on April 17, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that this scan is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET scan. Our reviewer says that the 
enrollee meets criteria for this PET scan. Our physician reviewer found the enrollee was diagnosed in 2006 and 
on several prior lines of therapy. The enrollee's prostate specific antigen (PSA) has increased to 23.57 as of 
August 24, 2023. The enrollee is being evaluated for Xofigo. This scan is considered a standard of care for 
restaging of prostate cancer with biomechanical elevations per guidelines. This service is medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Rituxan Hyclea. 
 
You asked the Plan to pre-approve Rituxan Hyclea. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
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 Rituxan Hyclea. Our reviewer says that 
the enrollee meets criteria for Rituxan Hyclea. Our physician reviewer found Rituxan Hyclea is not Food & 
Drug Administration (FDA) approved for the enrollee's diagnosis. However, this use is supported by one of the 
major drug compendia and is listed for off-label use by Medicare. Rituxan Hyclea has been shown to be safe 
and effective for acquired hemophilia treatment. It is reasonable and necessary 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 Rituxan Hyclea have been met. Therefore, we decided that the Plan has to pre-
approve use of Rituxan Hyclea.  
 
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 needs IRF services. The Plan denied 
your request. The Plan says an IRF admission is not reasonable and necessary for the enrollee.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  
 
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 Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is medically necessary. 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 Ondansetron.  Benefits for Ondansetron 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the requested imaging is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  We reviewed the file and the Medicare rules. We find that you are not 77 years of age or younger. Therefore, 
we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 32200 and 32220 rendered on November 
27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 32200: 
 
Pneumonostomy, with open drainage of abscess or cyst  
CPT 32220: 
 
Decortication, pulmonary (separate procedure); total 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 32200, the 
procedure report documents that "There was some cloudy fluid within the pleural space. This was suctioned 
and sent for culture."  For CPT 32200, the provider drains an abscess or cyst in the lungs using an open 
approach. This procedure was not found in medical record and therefore cannot be verified. 
 
In terms of CPT 32220, the procedure report does not include documentation of a total pulmonary 
decortication. This procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 32200 and 32220 rendered on November 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the readmission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an inpatient 
readmission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 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 inpatient hospital admission. Our 
reviewer says that the admission is not medically necessary. Our physician reviewer found that on October 4, 
2023, the enrollee re-presented to a local hospital with worsening abdominal pain and was transferred on 
October 5, 2023, with a diagnosis of recurrent transplant pancreatitis versus enteritis versus both. Imaging 
showed similar pancreatic inflammatory changes when compared to imaging done during the previous 
admission. Based on the medical records provided it does appear that the readmission resulted from a 
premature discharge from the same hospital with persistent findings of transplant pancreatitis.    
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paclitaxel, carboplatin, and pembrolizumab. 
 
You asked the Plan to pre-approve paclitaxel, carboplatin, and pembrolizumab. You say that the requested 
drugs are medically necessary. The Plan denied your request. The Plan says  the use of paclitaxel, carboplatin, 
and pembrolizumab for stage IV non-small-cell lung cancer with Eastern Cooperative Oncology Group 
(ECOG) performance status of 3 is not FDA approved or listed in the Medicare approved sources. 
 
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 paclitaxel, carboplatin, and 
pembrolizumab. Our reviewer says that the requested drugs are not medically necessary." Our physician reviewer found the FDA approved pembrolizumab in combination with carboplatin and either paclitaxel or 
nab-paclitaxel as the first-line treatment of metastatic squamous non-small cell lung cancer (NSCLC). The 
Keynote trial-042, which was the basis of the FDA approval used only ECOG 0 or 1 patients. Given the ECOG 
status of 3, the drug combination may not be safe in this case and thus not medically reasonable and necessary 
based on the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paclitaxel, carboplatin, and pembrolizumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve paclitaxel, carboplatin, and pembrolizumab.