Persius/hicric huggingface dataset:
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 need the chance to get better with the intensive 
rehabilitation and the SNF is not staffed well enough. The Plan denied your request. The Plan says the IRF care 
is not medically necessary, and your needs can be met at a lower level care such as a skilled nursing facility, 
home with home health services or home with outpatient therapy.  
 
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 you were admitted for gastrointestinal bleeding. Your medical problems are stable, 
and there are no complex nursing or rehabilitation needs. You do 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.  
 
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 skilled nursing services. 
 You asked the Plan to pre-approve the home health services. You say that the enrollee is in need of home 
health services. The Plan denied your request. The Plan says the enrollee does not require skilled care by a 
registered nurse.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our physician 
reviewer found that the enrollee has a past medical history of multiple medical comorbidities previously 
receiving home health services. Clinical documentation does not specify any acute clinical changes, medication 
changes, plan of care changes thus the records do not show that 6 additional home health skilled nursing visits 
are required to effectively provide treatment to improve the enrollee's condition, or to perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration.  
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that this is necessary for the enrollee. 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. Additionally, the record shows that this is not being given for the prevention or treatment of 
nausea and vomiting associated with cancer chemotherapy. Therefore, we decided that the Plan does not have 
to pre-approve Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter (E0118). You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that knee scooters and other crutch substitutes are not 
covered for any indication. Therefore, we decided that the Plan does not have to pre-approve a knee scooter 
(E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this procedure will provide long-term 
pain relief that will improve the enrollee's quality of life. The Plan denied your request. The Plan says the 
clinical value and effectiveness of a genicular artery embolization in the setting of knee osteoarthritis 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 the outpatient procedure. Our reviewer 
says that the requested a genicular artery embolization is not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery 
embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested genicular artery embolization 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular artery embolization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code G0480 and 83789) 
rendered on April 17, 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 there is insufficient information to corroborate the services. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also say that 
the physician must clearly document what laboratory tests are to be ordered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed CPT 
83789 is considered specimen validity testing which is not separately payable. Additionally, G0480 is not 
supported, as the records does not specify the specific drug classes that were being tested. Therefore, we 
decided that the Plan does not have to pay for laboratory services (procedure code G0480 and 83789) rendered 
on April 17, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided on March 30, 2023, 
billed with code 99214.  
 
You asked the Plan to pay for the medical services. You say that this was billed correctly and should be paid.  
The Plan denied your request. The Plan says that code 99214 cannot be paid as it was billed in the same month 
as code 90961 by the same provider.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is not valid in this case. The evaluation and 
management services at issue on this claim were related to an emergency medical condition and were not part 
of the end-stage renal disease (ESRD) monthly management services described by code 90961. 90961 reports 
the routine services provided related to ESRD. As such, the non-routine emergency room evaluation would not 
be considered to be reimbursed through 90961. Therefore, we decided that the Plan has to pay for the 
evaluation and management services provided on March 30, 2023, billed with code 99214.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause for the enrollee's pain. 
Therefore, the reviewer found that the Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (81003, 
87481, 87500, 87641, 87653, 87798 and 87801) provided on April 3, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary and 
reasonable. The Plan denied your request. The Plan says this panel was not medically necessary and is not the 
standard of care in this case. 
 
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 pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. The PCR testing is considered unproven and 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine PCR (polymerase chain reaction) panel (81003, 87481, 87500, 87641, 87653, 
87798 and 87801) provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
coverage requirements have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee has diabetes, 
uses insulin or has a history of problematic hypoglycemia. Based on this information, we decided that 
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from January 23, 2023, to April 1, 
2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says you did not bill these services with the appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a patient has a condition that exists bilaterally, 
and there is an existing ICD-10-CM code for that bilateral condition, providers should bill the bilateral code 
instead of individual codes for the left and right sides. 
 
In this case, you billed the following diagnoses on these claims:  I70.261 (Atherosclerosis of native arteries of 
extremities with gangrene, right leg) and I70.262 (Atherosclerosis of native arteries of extremities with 
gangrene, left leg).  However, a bilateral ICD-10-CM code exists for this scenario (code I70.263- 
Atherosclerosis of native arteries of extremities with gangrene, bilateral legs). You did not bill these claims with the appropriate bilateral diagnosis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from January 23, 2023, to April 1, 2023.
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 an IRF admission is medically necessary. 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 enrollee's nursing, medical and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. Documentation shows a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that this was originally denied in January. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drug, an injectable 
bisphosphonate (e.g., Pamidronate, Zoledronic Acid). 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, an injectable bisphosphonate. The reviewer found that 
there is no documentation provided indicating that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2600 units of Simponi aria. 
 
You asked the Plan to pre-approve Simponi aria. You say that as the enrollee's skin disease continues to flare, 
they will likely have progression of their disease which will lead to further complications possibly necessitating 
more extensive surgery or hospitalizations if the disease is not optimally controlled.  The Plan denied your 
request. The Plan says Simponi aria is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Simponi aria. Our reviewer says that 
Simponi aria is not medically necessary. Our physician reviewer found that the requested use of Simponi aria is 
not FDA- approved. Simponi aria is also not supported by one of the major drug compendia or by clinical 
research.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 2600 units of Simponi aria.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 5, 2022, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87500 and 87641. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 5, 2022, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87500 and 
87641.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 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 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. 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 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 acute inpatient rehabilitation facility (IRF) admission and services.