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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the clinical documentation shows that the enrollee has active medical 
comorbidities, but no complex functional impairments have been specified 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. The clinical documentation shows that 
the enrollee requires ongoing physical therapy and occupational therapy but does not show that the enrollee 
would require or tolerate an intensive rehabilitation regimen. The evaluating therapists document that the 
enrollee has low therapy tolerance and poor endurance. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Feraheme injection (codes Q0138 and 96365). 
 You asked the Plan to pre-approve a Feraheme injection. You say that due to the limitation of only using one 
arm, the enrollee will not be able to tolerate multiple intravenous infusions in one arm that Venofer requires. 
You also say that Feraheme, which is a total of only two infusions, would be well tolerated for this enrollee. 
The Plan denied your request. The Plan says Feraheme is a non-preferred product. The Plan also says the 
enrollee does not have any stated contraindications to the preferred products. 
 
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 a Feraheme injection. Our reviewer 
says that the enrollee does not meet the coverage criteria for a Feraheme injection. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Ferrlecit, INFeD, or Venofer. Our 
reviewer also found that the documentation does not support that Ferrlecit, INFeD, or Venofer would likely be 
less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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 Feraheme injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Feraheme injection (codes Q0138 and 96365).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee and K3 foot. 
 
You asked the Plan to pre-approve a microprocessor knee and K3 foot. You say that the requested prosthesis is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested 
microprocessor knee (Rheo) and K3 foot exceed the enrollee's need and is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that microprocessor knees and K3 feet are covered when 
medically appropriate for patients who are K3 ambulators. 
 
 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 microprocessor knee and K3 foot. Our 
reviewer says that the requested microprocessor knee and K3 foot are medically appropriate in this case. Our 
physician reviewer found the enrollee has the capacity to return to a high level of function. The microprocessor 
knee is associated with a lower level of falls and higher capacity to manage ramps and uneven ground for 
persons with an above the knee amputation. The evidence indicates enrollee is likely to be a high functioning 
K3 walker. 
 
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 microprocessor knee and K3 foot have been met. Therefore, we decided that 
the Plan has to pre-approve a microprocessor knee and K3 foot.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the requested epidural steroid 
injections are medically necessary. The Plan denied your request. The Plan says these services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered when 
certain criteria are met.  
 
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 epidural steroid injections. Our 
reviewer says that the requested epidural steroid injections are not medically necessary in accordance with the 
rules. Our physician reviewer found in this case, there is no documentation of radiculopathy. The review has 
determined that the enrollee does not have a diagnosis/condition that meets the criteria for the requested 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission based on medical necessity. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare guidelines for a SNF admission. 
 
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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311) and a pouch 
(K0108). 
 You asked the Plan to pre-approve the connection device and pouch. You say that the requested features are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that an electronic connection 
device is not medically necessary. The Plan also says that a pouch does not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 
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 connection device and pouch. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee does have use of the upper extremities and can operate and 
control the power options using the switches that are included in the basic wheelchair. 
 
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 connection device have not been met. A pouch does not serve a medical 
purpose. Therefore, we decided that the Plan does not have to pre-approve an electronic connection device 
(E2311) and a pouch (K0108).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pertuzumab (J9306) and trastuzumab (Q5116). 
 
You asked the Plan to pre-approve pertuzumab and trastuzumab. You say that pertuzumab and trastuzumab are 
standards of care in the neoadjuvant treatment of human epidermal growth factor receptor 2 positive (HER2+) 
breast cancers. The Plan denied your request. The Plan says that the use of pertuzumab and trastuzumab given 
as part of a clinical trial for HER2+ breast cancer is not FDA approved or listed in the Medicare approved 
sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pertuzumab and trastuzumab. Our 
reviewer says that pertuzumab and trastuzumab are medically reasonable and necessary for the enrollee. Our 
physician reviewer found the requested use of pertuzumab (J9306) and trastuzumab (Q5116) is FDA-approved 
for the enrollees diagnosis. The use is not listed as not indicated, not supported, or not recommended in any of 
the compendia. Our reviewer also found that the documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pertuzumab and trastuzumab have been met. Therefore, we decided that the 
Plan has to pre-approve pertuzumab (J9306) and trastuzumab (Q5116).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric bed is necessary to 
provide care to the enrollee. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The 
Plan denied your request. The Plan says you do not meet criteria for continued SNF care. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 31, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent 
situation that has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT services to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve PT services. You say that you need therapy on your wrist and hand due to 
having neuropathy and nerve damage causing to lose muscle in your lower arm. The Plan denied your request. 
The Plan says the services requested can be performed by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
PT services to be provided by an out-of-network (OON) provider.
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 reconsideration for 
the denial of an IRF admission based on medically necessary care. The Plan denied your request. The Plan says 
the 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 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that the enrollee would 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 18, 2021, to 
October 23, 2021, 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 the 
member presented with complaints of right flank pain. The member was alert and oriented. The member had 
metabolic and toxic encephalopathy that was transient, and it could be related to analgesics and kidney failure 
with possible urinary tract infection (UTI). The member had metabolic and toxic encephalopathy that was 
translent and it could be related to analgesics and kidney failure along with possible UTI. Therefore, diagnosis 
code G92.8-Other toxic encephalopathy is the appropriate secondary diagnosis code. The Plan denied your 
request. The Plan says The records submitted do not support secondary diagnosis code G92.8-Other toxic 
encephalopathy. 
 
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 secondary diagnosis code G92.8-Other toxic 
encephalopathy. 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 records submitted do not support secondary 
diagnosis code G92.8-Other toxic encephalopathy. Our physician reviewer found the enrollee presented after a 
presyncopal episode in the setting of narcotic use. The hospitalist attributed the episode to possible orthostasis, 
and this appears to have been billed as I95.2. There is no evidence that the enrollee had a separate and distinct 
diagnosis of toxic encephalopathy. Therefore, the billing of G92.8 is not supported.  
 
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 October 18, 2021, to October 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert system. 
 
You asked the Plan to pre-approve a Life Alert system. You say that the enrollee would greatly benefit from a 
life alert. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Life Alert system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for nerve conduction studies billed with code 95913 for date of service 
December 21, 2022. 
 
You asked the Plan to pay for code 95913. You say that code 95913 was billed correctly and should be paid. 
The Plan denied your request. The Plan says that it has paid for code 99204, but code 95913 is not supported by 
the medical record. 
 
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 95913 is Nerve conduction studies; 13 or more studies. 
 
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 code 95913. Our reviewer says that code 95913 is supported 
by the medical records. Our reviewer found the technical report in the medical records gives the breakdown of 
each test performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95913 have been met. Therefore, we decided that the Plan has to pay for 
nerve conduction studies billed with code 95913 for date of service December 21, 2022.  
 
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.