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

 
We decided that the Plan does not have to pre-approve nasal function studies (92512) and laryngeal function 
studies (92520). 
 
You asked the Plan to pre-approve nasal function studies and laryngeal function studies. You say that you need 
to do dynamic acoustic reflection to measure and record the size of the patient's nasal airway collapse and nasal 
function testing and evaluation turbinate areas for nasal breathing. You also say that you need to do dynamic 
acoustic testing for the patient's oropharyngeal structures to velopharyngeal hypopharynx and glottis aperture to 
ascertain the collapsed extent doing Mueller's maneuver. The Plan denied your request. The Plan says the 
clinical value and effectiveness of nasal function testing and laryngeal pharyngomanometry in the setting of 
obstructive sleep apnea have not been demonstrated in the peer-reviewed literature. 
 
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 nasal function studies and laryngeal 
function studies. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided medical records and review of the 
current peer-reviewed medical literature do not document that the nasal function studies (92512) and laryngeal 
function studies (92520) have been shown in controlled studies in a Centers for Medicare & Medicaid Services 
(CMS) approved journal to result in sustained long term health benefits in the Medicare population with 
obstructive sleep apnea as described in this clinical scenario. Our reviewer also found that the records do not 
document any unique historical features or examination findings in this case to support the necessity of the 
nasal function studies (92512) and laryngeal function studies (92520) beyond the testing already approved 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 nasal function studies and laryngeal function studies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve nasal function studies (92512) and laryngeal 
function studies (92520).
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 criteria for inpatient acute 
rehabilitation. You say the enrollee may be in harm's way if admitted to a skilled nursing facility level of care. 
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 enrollee's 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99232) 
rendered from August 30, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the determination in the records show that the diagnoses were related. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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. The claim was billed with diagnosis codes A09 
(other gastroenteritis and colitis of infectious and unspecified origin) and A19.7 (diarrhea, unspecified). 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 documents "Fluid-filled ascending colon, sigmoid colon and the rectum, in 
keeping up with patient history of diarrhea, may represent mild colitis." In this case, documentation does not 
support that the diarrhea is unrelated to gastroenteritis and colitis. Due to the ICD-10 guidelines for excludes1, 
the diagnosis of diarrhea would not be reported separately.  
 
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 evaluation and management services (procedure code 99232) rendered from August 30, 2023.
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 you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says step therapy requirements have not been met. 
 
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 
criteria for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a trial of 
Infed and Venofer before they will approve the requested drug. There is no indication that the enrollee has tried 
and failed the required drug(s). Based on the medical records provided and the Medicare-approved major drug 
compendia, there is no indication that the Plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says the services the enrollee needs can be provided safely in other settings, for example, a skilled 
nursing facility (SNF).  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 25, 2022, 
to February 11, 2022. 
 
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 several items and services initially denied for not having an itemized bill have now been 
identified as routine items and services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 multiple charges listed on the 
itemized bill summary describe personnel; routine and disposable supplies which would be included in the 
"room and board" charges. In this case, the services totaling $10,350.00 were denied appropriately, as the 
services were inappropriately unbundled. 
 
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 inpatient hospital services rendered from January 25, 2022, to February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are an ideal candidate for a power 
scooter. You say that your ability to perform activities of daily living (ADLs) has become severely limited. 
You also say that this is medically necessary. The Plan denied your request. The Plan says that the records do 
not show you cannot use a cane, walker, or manual wheelchair to complete mobility related activities of daily 
living (MRADLs). 
 
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. We find that the Plan did not provide medical records to support the fact that the 
item in this case should be denied. The provider in this case is shown to be a network provider and thus an 
agent of the Plan. We requested medical records, and none were provided. The Plan has not met the 
requirement of supplying us with all documentation needed to properly review the determination. Therefore, 
we decided that the Plan has to pre-approve a power scooter (K0800).  
 
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 enrollee has been recommended to an IRF due to 
recent surgeries and will not get the required number of hours at a skilled nursing facility. The Plan denied your 
request. The Plan says the IRF services you are requesting 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 enrollee's 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Treatment (IMRT) (77014, 77386, 
77470). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee has dosimetric studies that show some 
advantages to IMRT. The Plan denied your request. The Plan says that there is no good evidence IMRT is 
needed instead of other kinds of radiation. The IMRT would be considered unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this case appeal is somewhat complicated by the fact that there is no plan comparison to 
determine the need for IMRT. The insurer emphasizes that the dose is low, and the condition is benign. 
However, with benign conditions, the potential likelihood of a late complication is more relevant given the 
normal anticipated survival and balancing risks and benefits of treatment. Ultimately, this is a judgement call 
on whether standard medical necessity criteria would be met. The reviewer thinks it is a reasonable assumption 
that when treating in and around the orbit, that IMRT would be furnished in accordance with accepted 
standards of medical practice, even when delivering low to moderate doses of radiation. The decision is 
therefore favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Treatment (IMRT) (77014, 77386, 77470).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA), 
abdominal aorta and bilateral iliofemoral lower extremity runoff (75635). 
 
You asked the Plan to pre-approve a CTA of the abdominal aorta. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of a CTA. 
 
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 CTA of the abdominal aorta. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic back pain and lower extremity radiculopathy who 
reported left lower extremity swelling, redness, and peeling. Venous Doppler ultrasound was negative for 
thrombosis or other abnormality. A CTA abdominal aorta and bilateral iliofemoral lower extremity runoff with 
contrast was requested. However, the provided notes do not clearly describe the enrollee with an abnormal or 
equivocal ankle-brachial index measurement or arterial ultrasound which would be first line testing for 
suspected arterial occlusion/stenosis prior to considering more advanced imaging such as CTA. Also, the 
enrollee did not report symptoms suggestive of claudication or ischemia. Therefore, without sufficient support 
made, this request for CTA will be considered not medically necessary 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 a CTA of the abdominal aorta have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomographic angiography (CTA), abdominal aorta and 
bilateral iliofemoral lower extremity runoff (75635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64445-59 and 64447-59 rendered on 
February 13, 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 was an additional service provided by the anesthesia provider in addition to the anesthesia 
for the main surgery. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure report describes general anesthesia was performed, followed by regional anesthesia. In this case, documentation does not support anesthesia and injection for post-operative pain as separate services, as both 
were done at the same 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64445-59 and 64447-59 rendered on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that you are requesting a review of the denial of 
coverage for the Life2000 Ventilator. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in assist control (AC) mode with very low tidal volumes and low positive end-
expiratory pressure (PEEP) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe COPD with a forced expiratory volume in 1 second (FEV1) of 25% of 
predicted. The records do not include an arterial blood gas documenting chronic carbon dioxide (CO2) 
retention. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The Life2000 system 
is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to be used 
during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. The Life2000 system 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).