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 enrollee meets the full criteria for an IRF 
admission. The Plan denied your request. The Plan says an IRF admission is not medically necessary, but 
skilled therapies as an outpatient or at a skilled nursing facility (SNF) 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 clinical documentation shows that complex functional impairments have resolved, 
thus the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Clinical documentation supports the need for ongoing skilled therapy but not the medical necessity of an 
intensive rehabilitation regimen in an IRF setting. The IRF criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found there is no history of a fracture or of 
taking zoledronic acid previously. Our reviewer also found that the Health Plan uses step therapy and 
zoledronic acid is the first step. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 clinical documentation does not specify any complex functional impairments 
(encephalopathy/agitation resolved) thus the complexity of the enrollee's documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care.  Clinical documentation supports the need for ongoing skilled therapy but does 
not support the medical necessity of an intensive rehabilitation regimen in an IRF 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 80307 and G0483) 
rendered on May 23, 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 the denied codes remain 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. 
 
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 the submitted requisition is 
insufficient to show that the tests were medically necessary or that they were performed. As such, the billing of 
CPT 80307 and CPT G0483 is not supported.  
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 laboratory services (procedure code 80307 and G0483) rendered on May 23, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MRI of the abdomen. We decided that the Plan does not have to 
pre-approve MRI of the pelvis.  
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI) of the abdomen and pelvis You say that 
this is medically necessary for further evaluation. The Plan says that this is not reasonable and necessary under 
Medicare guidelines. 
 
We decided that the Plan has to pre-approve MRI of the abdomen.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 for the MRI of the abdomen. Our reviewer says that 
the enrollee was chronic epigastric pain, and unintentional weight loss of eight pounds in two months. The 
enrollee has had a negative endoscopic gastroduodenoscopy. There was a negative computed tomography (CT) 
of the abdomen and pelvis on August 30, 2023, except for abundant stool in the colon. The labs were normal. A 
review of the records shows concern of the pancreas due to distribution of pain and weight loss. Since CT of 
the abdomen and pelvis was essentially negative on8/30/23 MRI of the pancreas would be the next procedure 
of choice since her symptoms including epigastric pain and weight loss could be attributable to pancreatic 
cancer. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve MRI of the abdomen.  
 
We also decided that the Plan does not have to pre-approve MRI of the pelvis. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 for MRI of the pelvis. Our reviewer says that there is 
no justification for MRI of the pelvis included in the medical records. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MRI of the pelvis. 
 
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 medical records provided support the need for 
the requested IRF admission. 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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 they 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 rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  The enrollee can receive further services at a lower 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to care for self at home and 
will be starting dialysis and needs to be monitored around the clock. The Plan denied your request. The Plan 
says the enrollee's medical and therapy needs could be met in a skilled nursing unit.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 26 fractions of image-guided intensity-modulated 
radiation therapy (IG-IMRT). 
 
You asked the Plan to pre-approve 6 additional fractions of IG-IMRT. You say that you cannot start without 
full treatment requested. You say that there is little data treating pelvic/paraaortic fields with 20 fractions but a 
wealth of data treating these areas with 25 to 28 fractions. The Plan denied your request. The Plan says an extra 
6 fractions is not standard, not supported in the guidelines, and 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 6 additional fractions of IG-IMRT. Our 
reviewer says that the requested 6 additional fractions of IG-IMRT are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records indicate that the patient is being offered 26-fraction IMRT in the setting of a thoracic lymph node metastasis and many pelvic nodal metastases. 
For this patient, it is questionable if the extent of disease would qualify as low volume. Nevertheless, a 
palliative course of radiotherapy is reasonable. The reviewer found that the delivery of more than 20 fractions 
of radiation in the metastatic setting seems outside of the standard of care based on NCCN guidelines. The 
reviewer also found that there is no plausible justification for more than 20 fractions. Therefore, the reviewer 
found that the requested 6 additional fractions 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 6 additional fractions of IG-IMRT have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 26 fractions of image-guided intensity-modulated radiation therapy 
(IG-IMRT).
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 medical records provided support the need for 
the requested IRF admission. 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 a stroke. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee had an adverse reaction to Boniva. You 
also say that the enrollee has agreed to try Prolia. The Plan denied your request. The Plan says the enrollee has 
not tried and failed intravenous (IV) bisphosphonate therapy, such as zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation indicates that the 
enrollee has not tried and failed the preferred drug, zoledronic acid. The reviewer also found that there is no 
indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair (TTVR).. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary.  The Plan denied 
your request. The Plan says there is no documentation to support the enrollee will be participating in a clinical 
trial. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of TTVR in this patient. Based on 
current clinical guidelines, there are insufficient randomized clinical data at this time to support the use of 
TTVR in this setting. As such, it would not be considered medically appropriate and necessary in this patient's management. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter tricuspid valve repair (TTVR)..
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 services are medically necessary for you to return 
to your prior level of function. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.