Persius/hicric huggingface dataset:
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 requires long term care for 
nutrient gastric tube, physical therapy, occupational therapy, respiratory physical therapy, and for treatment of 
acute respiratory failure. You say that the long-term care needed would be appropriately provided at an 
LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care 
and is currently unstable for transfer to an LTACH. 
 
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 documentation supports that the enrollee does require long term care for feeding, ventilation support, nursing care, occupational therapy, and physical therapy. However, the documentation does 
not show that these services could not be provided in the current health care setting. There is no documentation 
to support that these necessary services cannot be provided in the current health care facility 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 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray 
(D0330) provided on June 22, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330). 
You say that you were unaware that there were frequency limits for these procedures. The Plan denied your 
request. The Plan says that the benefits have been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan did not send documentation showing that they paid for an evaluation or 
panoramic x-rays within the frequency limits. Please note, the Plan paid for the crowns (D2710x2) and the 
analgesia (D9230). Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation 
(D0150) and the panoramic x-ray (D0330) provided on June 22, 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: 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 admission to the IRF is not 
reasonable and necessary, as the enrollee's condition does not meet Medicare guidelines 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 the complexity of the enrollee's 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, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00794 provided April 25, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 00794 is anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; pancreatectomy, partial or total (for example, Whipple procedure). 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The medical record documents general anesthesia; however, the 
anesthesia report was not found in documentation. The documentation supports a block was performed; however, the anesthesia service 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 00794 provided April 25, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance transport services provided on April 3, 
2023. 
 
You asked the Plan to pay for the non-emergency ambulance transport services. You say that the services were 
medically necessary for the enrollee to receive their dialysis treatments. The Plan denied your request. The Plan 
says that the non-emergent ambulance services do not meet the criteria for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport 
services. Our reviewer says that the services were medically necessary. Our physician reviewer found at the 
time of transport the enrollee had generalized weakness requiring assistance. It appears that with assistance the 
enrollee was able to stand and pivot. However, they were on continuous oxygen, and it is unclear whether they 
could self-administer. Therefore, other means of transport may be contraindicated.  
 
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 non-emergency ambulance transport services have not been met. Therefore, 
we decided that the Plan has to pay for the non-emergency ambulance transport services provided on April 3, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 rendered on July 12, 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 this does not meet coding standards. 
 
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 29581 is "Application of multi-layer compression 
system; leg (below knee), including ankle and foot." 
 
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 procedure report describes 
debridement to right leg, and covered with dry sterile dressing and 3 layer unna boot compression dressing system.  In this case, dressings are included in the debridement procedure, as both services were provided on 
same anatomical area, right leg. 
 
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 code 29581 rendered on July 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the drug in 
dispute. The Plan denied your request. The Plan says the use of Keytruda for this enrollee's treatment is not 
supported. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has locally advanced versus 
metastatic vulvar cancer. The enrollee has not received prior chemotherapy. The requested use of Keytruda is not FDA-approved as a first line of therapy (monotherapy) for the enrollee's diagnosis. The use of Keytruda in 
this setting is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 skilled nursing visits. 
 You asked the Plan to pre-approve the skilled nursing visits. You say that the enrollee requires continued 
nursing visits for their medical needs. 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 the skilled nursing visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee's 
condition is stable. The enrollee does not require skilled nursing services. Therefore, the services cannot be 
approved at this time. 
 
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 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on February 8, 2023. 
  
You asked the Plan to pay for the hearing aids. You say that you received a better rate and chose to go out-of-
network instead. The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on February 8, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl.  
 
You asked the Plan to pre-approve Reblozyl. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says that the requested drug is not medically necessary.  
 
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 Reblozyl. Our reviewer says that the 
use of the requested drug is medically necessary. Our physician reviewer found the use of the requested drug is 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal, Lancet Oncology Articles| Volume 18, Issue 10, P1338-1347, October 2017. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl.   
 
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 services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting on an 
intermittent basis.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 14, 2022, 
to September 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that sepsis, 
unspecified organism, is the correct principal diagnosis. The Plan denied your request. The Plan says the 
Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient 
hospital services with the incorrect DRG. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 the enrollee was treated in the hospital for 
pneumonia in the setting of endobronchial mass (squamous cell carcinoma of the lung). Workup revealed 
normal blood pressure, normal platelet count, normal creatinine, normal bilirubin, no oliguria, normal mental 
status, and normal oxygen saturation (SpO2) on supplemental oxygen. The enrollee used home oxygen and 
continued the use of this in the setting of multiple pulmonary factors contributing to the hypoxia, this was 
expected. There were no other significant signs of organ failure that would suggest a dysregulated response to 
systemic infection as required to meet Sepsis 3 criteria. Therefore, the diagnosis code, A41.9 (sepsis) is not 
supported for this admission, and the DRG 194 would be more appropriate.  
 
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 provided on September 14, 2022, to September 21, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 fractions of Intensity-Modulated Radiation Therapy 
(IMRT). 
 
You asked the Plan to pre-approve the 30 fractions of IMRT. You say that the records provided support the 
need for IMRT services. The Plan denied your request. The Plan says Medicare rules say that the special 
radiation must show an advantage or improvement over other forms of radiation. The Plan says that other 
forms of radiation would be considered medically necessary, but that IMRT would not be considered medically 
necessary.  
 
The Plan follows Medicare rules. Medicare rules say that IMRT is covered when medically necessary and 
when there is documented rationale of the advantage of IMRT versus the use of other radiation therapy 
methods.  
 
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 30 fractions of IMRT. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has metastatic 
pancreatic cancer to the lung. It is unclear whether the enrollee saw a medical oncologist, whether systemic 
therapy was offered, and/or whether the enrollee received (or declined) systemic therapy. It is also unclear 
whether a repeat imaging (preferably positive emission tomography) was done for restaging given a long 
interval from the initial positive emission tomography (PET) on May 10, 2023, and considering the biology of 
metastatic pancreatic cancer with the possibility of disease progression over the course of approximately 6 
months. Taken together, it is unclear whether the plan for a long course of radiation treatment to pancreatic 
mass (assumed primary) and the lung nodules (metastases) was in the setting of oligometastses 
(oligoprogression). In the lack of this information, 30 fractions of IMRT are not medically necessary. The 
IMRT is not medically necessary for standard palliative courses of radiotherapy (XRT), especially in this case 
given the presence of several pulmonary metastases. Other radiotherapy techniques like three-dimensional 
conformal radiation therapy (3DCR) and another dose can be used in lieu of 30 fractions of IMRT if palliative 
radiotherapy is indicated for symptom control. 
 
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 30 fractions of IMRT have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 30 fractions of Intensity-Modulated Radiation Therapy (IMRT).