Persius/hicric huggingface dataset:
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 will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home. The enrollee requires 
interdisciplinary therapy care (occupational therapy, physical therapy).  The Plan denied your request. The Plan 
says based on Medicare guidelines and the information we have about the enrollee's condition they don't meet 
all of the requirements. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for diabetic ketoacidosis and a rib fracture. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection of Anesthetic Agent (Nerve Block) (64454). 
 
You asked the Plan to pre-approve Injection of Anesthetic Agent. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says experimental are not covered 
 
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 Injection of Anesthetic Agent. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found this procedure is 
considered experimental and is the subject of ongoing clinical trials.  Therefore, the request is deemed not 
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 Injection of Anesthetic Agent have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Injection of Anesthetic Agent (Nerve Block) (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36000, 99070, 99072, 99153, and A4930 
rendered on May 4, 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. Medicare rules also say that the OPPS 
recognizes that CPT code 99153 is a PE only code and that PE are not payable to the physician for services 
provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 
 
We also find that payment for A4930 is not supported. This code has a status indicator of X, which indicates 
the code is statutorily excluded from coverage. 
 
We find that procedure codes 36000, 99070, and 99072 have a status indicator of B on the Physician Fee 
Schedule. This means that these procedure code are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of these codes have not been met. 
 
We looked at 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 36000, 99070, 99072, 99153, and A4930 rendered on May 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta (J7351). 
 
You asked the Plan to pre-approve Durysta. The Plan denied your request. The Plan says this is an off-label use 
and the product label and compendia do not support re-implantation. 
 
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 Durysta. Our reviewer says that 
Durysta is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of open-angle glaucoma, status post placement of Durysta implant. 
The FDA has stated that the requested drug is for one time administration. Our reviewer found that the 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. Our physician reviewer also 
found that 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 Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta (J7351).
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 Inpatient Rehabilitation Facility admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have 
complex medical or intensive rehabilitation needs requiring supervision by a rehabilitation physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2313, E2311, E2377) and a 
solid insert (E0992). 
 
You asked the Plan to pre-approve the upgraded electronics and a solid insert. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the upgraded 
electronics are not medically necessary. The Plan also says that the requested solid insert is denied as 
unbundled. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary for the enrollee to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that these items are not medically necessary. Our physician reviewer found that the enrollee has adequate 
strength to manage a standard power drive. The requested accessories are not necessary to meet the enrollee's 
needs. 
 
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 upgraded electronics have not been met. The requested solid insert is not 
separately payable due to a solid base is included in the allowance of the approved codes. Therefore, we 
decided that the Plan does not have to pre-approve the upgraded electronics (E2313, E2311, E2377) and a solid 
insert (E0992).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing the denial of some 
requested visits for the enrollee. 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 that the 
records do not show that skilled therapy services are required in the home setting to effectively provide 
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a 
maintenance program to maintain the enrollee's level of function 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 11 home health physical therapy visits.
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 admission to Inpatient Rehabilitation Facility 
services is medically necessary for you. The Plan denied your request. The Plan says your records do not show 
that you have complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor. 
 
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. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-cardiac vascular flow imaging (78445).

You asked the Plan to pre-approve the service. You say that this procedure is necessary due to COVID-related
thrombosis to evaluate for aneurysm. The Plan denied your request. The Plan says the requested examination
is neither reasonable, necessary, nor is it likely to yield any useful information. The Plan states this is an
obsolete procedure that has no current indications.

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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that this situation is most likely simply a clerical/coding error. The provider correctly notes that
evaluation for a more proximal source of embolism is warranted perhaps with a computed tomography (CT)
angiogram. This is a very reasonable and appropriate recommendation however the code used in requesting the
study calls for a nuclear medicine study that, as noted by the Health Plan, would be of limited or no value. It
also does not appear to at all be the study that the provider is interested in obtaining. Recommend the provider
review and resubmit the request with the appropriate coding. Our physician reviewer agrees with the Health
Plan determination.

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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve non-cardiac vascular flow imaging (78445).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special kind of injected radiation therapy for cancer in 
the liver (implantable Beta-Emitting Microspheres also known as Y-90) (77370, 77470, 79445). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the role of Y-90 radioembolization (SIRT) here is completely unknown and 
meets the definition of experimental. The Plan states the planned course of action is not present in any known 
guidelines including the National Comprehensive Cancer Network (NCCN). The Plan states the clinical utility 
here is highly questionable for SIRT.  
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not sufficiently justify the need for radioembolization which seems outside the 
standard of care for the treatment of a small, solitary asymptomatic liver metastasis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a special kind of injected radiation therapy for cancer in the liver (implantable Beta-
Emitting Microspheres also known as Y-90) (77370, 77470, 79445).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's records 
received do not indicate the need for an intensive therapy program with multiple visits from a rehabilitation 
doctor. 
 
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. 
 
 
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 the enrollee needs long term care facility 
care in order to regain maximum function. The Plan denied your request. The Plan says the enrollee's records 
do not show they need continued treatments and care that can only be given in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only requires acute care that can 
safely be provided at the current facility until more appropriate for a lower level of care. The enrollee does not 
require services at the LTACH that are not already available at the current facility. 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: 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 will benefit from acute inpatient 
rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
based on Medicare guidelines, the inpatient rehabilitation facility (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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for dizziness and unsteady gait. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code A0425 for date of 
service January 4, 2023. 
 
You asked the Plan to pay for code A0425. You say that this transportation was medically necessary. The Plan 
denied your request. The Plan says you have billed too many units of this code on a single claim line. 
 
The Plan must follow Medicare rules. Medicare rules say that that ambulance services billed with code A0425 
have a Medically Unlikely Edit (MUE) of 250 miles.  This is the maximum number of units billable on a single 
line of the claim.  If you report this code with units greater than the MUE, the claim will deny. 
 
In this case, you billed 328 units of code A0425 on a single claim line.  You are only permitted to bill 250 units 
on a single claim line.  If additional units of this code were required, they would need to be billed on a second 
claim line with an appropriate modifier.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services billed with code A0425 for date of service January 4, 2023.