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 services are medically necessary for the enrollee 
to regain their maximul level of function. The Plan denied your request. The Plan says the enrollee does 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that the medication is medically necessary for the 
enrollee's medical condition. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for the medication being requested. 
 
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 Truxima. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of immunoglobin G4 related pseudotumor. 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. The elements of the 
coverage criteria 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Invitae Familial Hemiplegic Migraine Panel. 
 
You asked the Plan to pre-approve the Invitae Familial Hemiplegic Migraine Panel. You say that this testing 
was medically necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. We find that this test has not been approved for coverage based on 
information in the DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for 
coverage of the Invitae Familial Hemiplegic Migraine Panel have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Invitae Familial Hemiplegic Migraine Panel.
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 very weak and needs physical and 
occupational therapy to gain strength to be able to perform their daily activities. You say the enrollee needs 
help with wound care and managing their ostomy. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in 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 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 
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 meet criteria for admission to an acute 
inpatient rehabilitation facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring device (K1024, K1032). 
 
You asked the Plan to pre-approve a Koya Dayspring device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Koya Dayspring device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device has not been shown to be superior to other standard treatments 
for the medical condition. The studies do not indicate the Koya Dayspring Active Compression Garment 
System improves an individuals function or general health compared to standard treatment. The requested device is not medically 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 Koya Dayspring device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Koya Dayspring device (K1024, K1032).
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 and exceeds the CMS 
requirements for IRF level of care. The Plan denied your request. The Plan says the enrollee's records do not 
show that rehabilitation needs are complex. The Plan says that the services needed may be provided safely in a 
lower level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided on April 14, 2023, and 
April 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded". The CPT Code Manual definition of code 99233 is 
"Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded". 
 
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 use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision-making of a high level, so code 99223 is 
not supported for April 14, 2023. The documentation supports an appropriate exam, but not an appropriate 
history or medical decision making of a high level, so code 99233 is not supported for April 15, 2023. 
 
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 the services (99223, 99233) provided on April 14, 2023, and April 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab injections. 
 You asked the Plan to pre-approve Romosozumab injections. You say that the requested drug is medically 
necessary for the enrollee's current medical condition. The Plan denied your request. The Plan says the 
requested drug does not meet the criteria for approval. 
 
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 Romosozumab injections. Our reviewer 
says that the requested drug does not meet the step therapy requirements for approval. Our physician reviewer 
found the provided records do not indicate that the enrollee has tried and failed a trial of an injectable 
bisphosphonate. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the plan's preferred step one alternative. The requested service cannot be recommended as 
the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romosozumab injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Romosozumab injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, upgraded electronics, and height adjustable joystick mount. 
 
You asked the Plan to pre-approve the upgraded electronics and adjustable joystick mount. You say that the 
physical therapy evaluation indicates that the enrollee has no use of their left side and very little on their right 
side. The Plan denied your request. The Plan says the notes do not show a medical need to control the power 
options through the joystick. The Plan also says joystick mounting hardware is included with requested 
controller and cannot be covered separately. 
 
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 upgraded electronics and adjustable 
joystick mount. Our reviewer says that the requested upgraded electronics and adjustable joystick mount are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation does not support that it is medically necessary to control the requested power options through 
the joystick. Therefore, the reviewer found that the requested upgraded electronics and adjustable joystick 
mount 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 upgraded electronics and adjustable joystick mount have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options, upgraded electronics, and height adjustable joystick mount.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
  You asked the Plan to pre-approve SNF care. You say that the enrollee's level of functioning has decreased 
compared to prior admission. You say that the enrollee would like to continue to benefit from skilled physical 
therapy to increase functional mobility and strength.  The Plan denied your request. The Plan says a SNF 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 discharged home without 
rehabilitation and is unsafe being home alone needing rehabilitation to regain mobility. The Plan denied your 
request. The Plan says the enrollee's records do not require a rehabilitation doctor at least three times a week or 
the need for an intensive team (rehab nurse, social worker, and therapists) for care.  
 
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 a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you need the reclining wheelchair to 
ease the pain in her back. The Plan denied your request. The Plan says you do not meet the criteria for tilt and 
recline features.  
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is only covered under 
certain medical indications. 
 
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 requested wheelchair. Our physician 
reviewer found that the documentation indicates the patient has a mobility deficit that impairs mobility related 
activities of daily living in the home and is not ameliorated by a walker, cane, manual wheelchair due shoulder 
and upper extremity pain. While the enrollee may be able to safely operate a power mobility device, the 
requested device exceeds the enrollees medical needs. The documentation does not reveal that the enrollees 
needs is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder 
management, or needs a power seating system to manage increased tone or spasticity. There is no evidence of a 
need for a ventilator. Therefore the requested wheelchair and related accessories are not medically 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 requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair with multiple power options.
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 requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says your 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity revascularization procedure (37220, 
37224, 37225, 37227, 37229). 
   
You asked the Plan to pre-approve a lower extremity revascularization procedure. You say that this is 
medically necessary. The Plan denied your request. The Plan says there is no documentation the enrollee has 
failed medical management and a home exercise program and continued to have significant activity limiting 
disease. There is no documentation of ischemic rest pain and non-healing ulcers, consistent with limb 
threatening ischemia. 
 
The Plan follows Medicare rules. Medicare rules say that this item or service is 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 a lower extremity revascularization 
procedure. Our reviewer says that there is insufficient documentation to support the medical necessity for lower 
extremity revascularization in this enrollees clinical management. Our physician reviewer found while the 
enrollee has a history of peripheral vascular disease, there is no evidence of ischemic rest pain. The ankle-
brachial index is .78 bilaterally. There is no evidence of failed guideline-directed medical 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 a lower extremity revascularization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity revascularization procedure (37220, 
37224, 37225, 37227, 37229).