Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that 
Retacrit is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
glomerular filtration rate of less than 30 and a hemoglobin of less than 10 mg/dl. The record indicates that the 
enrollee is iron deficient, and iron has not been repleted. Therefore, the reviewer found that the requested drug 
is 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the requested drug is necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Venofer. 
 
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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred drug, Venofer. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred. 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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. The Plan denied your request. The Plan says the 
enrollee can remain in the current hospital until no further acute level of care is needed. Services needed may 
be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99336 billed for date of service December 19, 2022. 
 
You asked the Plan to pay for code 99336. You say that you billed these services correctly. The Plan denied 
your request. The Plan says the code you billed (99336) is inconsistent with the POS code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that that providers must bill the appropriate Place of 
Service (POS) code on their claims.  POS 12 indicates that the service was performed in the patient's home.  
POS code 13 indicates that the service was performed at an assisted living facility. 
 
In this case, you billed procedure code 99336 (Level 3 established patient domiciliary, rest home, or custodial 
care visit) with a POS code of 12.  However, the billing of this procedure code indicates that the service 
occurred in a domiciliary, rest home, or custodial care setting.  Further, in your appeal itself, you confirmed 
that these services were rendered in an assisted living facility, not in a home setting.  As a result, you should 
have billed POS code 13, not 12. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99336 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99336 billed for date of service December 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is proven to be effective for the 
enrollee's condition.  The Plan denied your request. The Plan says the enrollee's back pain is multifactorial 
which means this procedure is not reasonable and 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records does not include advanced imaging showing that the enrollee has 
only Modic endplate changes, and the absence of facet joint degeneration and/or foraminal stenosis. This does 
not support the necessity of 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intracept basivertebral nerve ablation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99222) provided on February 2, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99222 is Initial Hospital Care for the evaluation and 
management of a patient with a comprehensive history, a comprehensive examination, and medical decision 
making of moderate complexity. 
 
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 inpatient care. Our reviewer says that the records 
provided do not support the code billed. Our reviewer found the records provided do not show a comprehensive history was 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 the inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient care (99222) provided on February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT guidance for placement of radiation therapy fields 
and stereoscopic x-ray guidance. 
 
You asked the Plan to pre-approve the radiation guidance. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is not enough medical evidence to show that this 
type of radiation guidance is effective to treat your cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 to pre-approve the radiation guidance. Our reviewer 
says that the request is not medically reasonable and necessary. Our physician reviewer found that when 
treating skin cancers, there is generally not a need for image-guided radiation therapy (IGRT) unless deep 
structures are being treated. This situation does not apply to the enrollee for which the target lesion can be seen 
on the skin to assist in daily set up. IGRT is neither standard of care for skin cancers nor is the need supported 
in the medical record. 
 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 radiation guidance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT guidance for placement of radiation therapy fields and stereoscopic x-ray 
guidance.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can 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 that the enrollee is medically stable, and does not require physician supervision three 
times a week in the IRF. There are no documented rehab or nursing needs. An uncomplicated hip fracture does 
not require IRF admission. The enrollee does not need specialized and intensive therapies consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. Needs can be 
provided in a lower intensity and alternate setting such as in an SNF. 
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary because you are 
finding it impossible to heal due to your living situation, and you feel you would be able to thrive under more 
direct and regulated care. The Plan denied your request. The Plan says you do not meet the Medicare 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that you have a family history of dementia, and your 
provider says you have the symptoms of early stage dementia. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that you have memory loss. According to 
the applicable NCD, a PET scan of the brain is covered for use in individuals who meet diagnostic criteria for 
both AD and FTD. No such behavioral issues are documented to make the case for possible FTD. Therefore, a 
PET scan cannot be covered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E0955, E0956, E0960, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for multiple power options included with the 
K0861 group 3 power wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. The criteria for the 
specific wheelchair requested has 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories (K0861, E0955, E0956, E0960, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable and necessary. Our physician reviewer found that the record shows 
there are no details concerning the short-term memory loss and in particular no Mini-Mental State Examination 
(MMSE) testing to document cognitive decline. Neurological exam was negative. The request cannot be 
recommended at his 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is chronically ill and has 
multiple medical issues and comorbidities that are currently too complicated for a skilled nursing facility. The 
Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is medically stabilized for discharge but 
is unable to be safely discharged to their home. The Plan denied your request. The Plan says criteria for 
admission to the IRF have 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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital admission and care related 
to a total knee arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that this procedure cannot be 
safely done as outpatient for the enrollee. The Plan denied your request. The Plan says the inpatient admission 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided documentation does not support that the procedure in this case 
cannot be safely performed as outpatient. Therefore, the reviewer found that the requested inpatient admission 
is 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 acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the acute inpatient hospital admission and care related to a total knee 
arthroplasty.