Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee has severe arthritis and 
bursitis and a poor support system. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 11 additional home health physical 
therapy visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found that clinical documentation shows that skilled therapy services would be required for the 
enrollee's clinical conditions. However, it does not show that the enrollee is home bound or that the enrollee 
would require 11 additional home health physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 11 additional home health physical therapy visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Durolane. 
 You asked the Plan to pre-approve Durolane. You say that physical therapy would cause more pain and 
damage. The Plan denied your request. The Plan says the Plan requires a trial of Monovisc, Orthovisc, Synvisc, 
or Synvisc-One before it will approve Durolane. 
 
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 Durolane. Our reviewer says that you 
do not meet criteria for a step therapy exception for Durolane. Our physician reviewer found you have not tried 
and failed one of the Plan's preferred drugs of Monovisc, Orthovisc, Synvisc, or Synvisc-One. The record does 
not show that these drugs would likely be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Durolane.
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 services are necessary for the 
enrollee to receive the most appropriate level of care and have the most optimal opportunity for a successful 
outcome. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
setting. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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: 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 are appealing with supporting records. 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 the enrollee was only identified as 
having a cognitive impairment. According to the applicable NCD, PET scan of the brain is covered for use in 
individuals who meet diagnostic criteria for both AD and FTD. However, the records did not indicate that the 
enrollee met the diagnostic criteria requirements for either let alone both AD and 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve the medication. You say that you were not informed this medication is only 
covered under Part D. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gammagard.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
March 19, 2022, and March 20, 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 Current Procedural Terminology (CPT) code 99233 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 in this case, the documentation 
doesnt support the CPT code 99233. The documentation available for review does not support that the enrollee 
developed a significant complication or that medical decision making of high complexity was needed. 
 
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 subsequent hospital care (procedure code 99233) rendered on March 19, 2022, and March 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that medical records were submitted to 
support the reconsideration of the denied lightweight wheelchair. The Plan denied your request. The Plan says 
the requested services are not reasonable and necessary, and the health plan has no contractual obligation to 
cover services that are not covered by Medicare. The enrollee is able to self-propel a standard wheelchair. 
 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 lightweight wheelchair. 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 a past medical history including cardiac disease and congestive heart 
failure and has had multiple falls at home. According to Medicare a high strength lightweight wheelchair is 
covered when an enrollee is able to self-propel the wheelchair while engaging in frequent activities in the home 
that cannot be performed in a standard wheelchair or the enrollee requires a seat width, depth, or height that 
cannot be accommodated in a standard, light weight or hemi-wheelchair, and spends at least two hours per day 
in the wheelchair. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected 
duration of need is less than three months. In this case, there is no clear indication that the enrollee requires a 
lightweight wheelchair to self-propel while engaging in frequent activities in the home that cannot be 
performed in a standard 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 a lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for a partial hospitalization. 
 
You asked the Plan to pay for a partial hospitalization. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a partial hospitalization is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that partial hospitalization is used to shorten an inpatient 
stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, 
intense, structured combination of services provided by a PHP. 
 
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 a partial hospitalization. Our reviewer says 
that a partial hospitalization is medically necessary. Our physician reviewer found the enrollee required partial 
hospitalization due to increased anxiety and depression with increased isolation due to relapsing symptoms. 
 
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 partial hospitalization have been met. Therefore, we decided that the Plan has 
to pay for a partial hospitalization.  
 
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 for the enrollee. 
The Plan denied your request. The Plan says the enrollee's medical needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 You asked the Plan to pre-approve home health services. You say that you are having issues with your leg.s 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have any documented skilled nursing needs. There are no documented skilled therapy needs. As such, these 
services are not shown to be 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient clinical study services provided on September 
14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that institutional providers billing clinical trial 
service(s) must report ICD-9 diagnosis code V70.7 if ICD-9 is applicable or, if ICD-10-CM is applicable, ICD-
10 diagnosis code Z006 in either the primary or secondary position and a condition code 30 regardless of 
whether all services are related to the clinical trial or not.  
 
We looked at the file and Medicare rules. In this case, the claim was not billed with condition code 30 as 
required. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient clinical study services provided 
on September 14, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney imaging morphology; with vascular flow and 
function, single study, with pharmacological intervention (78708). 
 
You asked the Plan to pre-approve kidney imaging morphology. You say that you have been experiencing 
spotting. You say that your uterus was removed. You also say that you are experiencing pain in your lower 
back. The Plan denied your request. The Plan says the requested imaging is not medically 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 kidney imaging morphology. Our 
reviewer says that the requested kidney imaging morphology is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of endometrial cancer in 2020 
and has denied radiation therapy. The reviewer found that the use of a three-phase nuclear medicine study for renal function is necessary when there is suspicion of decreased renal function due to hydronephrosis and 
quantification of renal function is necessary to determine the degree of remaining function in the face of 
hydronephrosis seen on ultrasound or computed tomography (CT).  No imaging reports describing any sort of 
hydronephrosis are in the submitted records.  Thus, the medical necessity of the requested three-phase nuclear 
medicine study has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kidney imaging morphology have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a kidney imaging morphology; with vascular flow and function, single 
study, with pharmacological intervention (78708).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19083 and 19084 billed for July 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 19083 and 19084 are not supported. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 19083 was not billed with a 
required anatomical modifier. Given that the primary procedure code 19083 is not covered due to improper billing, add-on code 19084 is also not supported. Therefore, we decided that the Plan does not have to pay for 
procedure codes 19083 and 19084 billed for July 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial 
of a continued SNF stay. The Plan denied your request. The Plan says your request does not meet Medicare 
guidelines for continued SNF services. 
 
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. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on October 
13, 2022, billed with codes 87481, 87496, 87500, 87511, 87529, 87532, 87541, 87651, 87653, 87661 and 
87798. 
 You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on October 13, 2022, billed with codes 87481, 87496, 87500, 
87511, 87529, 87532, 87541, 87651, 87653, 87661 and 87798.