Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that you have active medical comorbidities and 
complex functional impairments thus the complexity of your documented nursing, medical and rehabilitation 
needs would be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation shows that you require ongoing therapies, and the neurological 
association recommends an IRF however the clinical documentation shows that you have new agitation and 
electrolyte abnormalities thus you are not yet medically stable for an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 7, 2022, to 
September 9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical record provided clear, consistent documentation and supportive evidence of J96.01 (Acute hypoxic 
respiratory failure). The Plan denied your request. The Plan says the documentation does not clinically validate 
the billing of diagnosis J96.01 (Acute hypoxic respiratory failure).  As a result, a different DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the diagnosis of J96.01 (Acute hypoxic respiratory 
failure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our reviewer says that the diagnosis of J96.01 (Acute hypoxic respiratory failure) is not 
supported in the medical record. Our physician reviewer found the patients oxygen saturation was 90% on 
room air after ambulating to triage at presentation to the emergency department. His respiratory rate initially 
was 24 per minute and decreased to a normal range and his saturation improved to 93% to 99% with 2.5 to 4 
liters nasal cannula oxygen. He was also treated with intravenous antibiotics and weaned off oxygen to room 
air during the hospital stay and discharged to home on September 9, 2022. The provided records do not support 
that the patients respiratory condition was of such severity as to warrant the diagnosis of acute hypoxic 
respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 7, 2022, to September 9, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex (daratumumab) (J9145). 
 You asked the Plan to pre-approve daratumumab. You say that the enrollee is under your care for their 
diagnosis of Multiple Myeloma, and they are not eligible for a transplant. You also say that the enrollee has 
markedly elevated light chains and is in need of intravenous therapy treatment with daratumumab. The Plan 
denied your request. The Plan says Darzalex is a non-preferred product. The Plan also says the enrollee does 
not have any stated contraindications to the preferred products. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve daratumumab. Our reviewer says that 
the enrollee does not meet the coverage criteria for daratumumab. Our physician reviewer found the enrollee 
has not tried and failed the Plan's required drugs. Our reviewer also found that the documentation does not 
support that bortezomib or Velcade would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daratumumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darzalex (daratumumab) (J9145).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fiasp Flextouch. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 Fiasp Flextouch.   
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 88344 for date of service March 
1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says Medicare guidelines require various unusual pathology findings to qualify 
for the IHC stains and your medical records do not show these findings. 
 
The Plan follows Medicare rules. Medicare rules say that it is not reasonable and necessary to perform IHC 
testing (either single antibody or antibody cocktails) on cases with morphologically negative cores. It is not 
reasonable and necessary to perform IHC testing in a negative or a suspicious core biopsy when obvious 
prostate cancer is present in other cores. 
 
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 lab services. Our reviewer says that this 
lab service was not medically necessary in accordance with the LCD. Our physician reviewer found the patient did not meet any of the clinical reasons for medical necessity laid out in the LCD above. The doctor found that 
the patient falls into the scenario of "In a multi-part biopsy with =3+4=7 cancer in 1 part, and ASAP suspicious 
for 3+3=6 cancer in other part(s), because stains are unlikely to change treatment."  This is one of the scenarios 
listed for non-coverage of this IHC testing. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services billed with code 88344 for date of service March 1, 2022.
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 meets criteria for admission 
to the LTACH and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 there is no evidence that the enrollee requires services that are not currently 
available. The enrollee can remain at the current acute care hospital until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on September 13, 2022 
 
You asked the Plan to pay for the injections. The Plan denied your request. The Plan says this provider chose 
not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for injections 
provided on September 13, 2022
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 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 enrollee is functioning near a home care level and does not require intensive 
rehabilitation services or frequent physiatry oversight. The cervical spine has been stabilized and he is walking 
weight bearing as tolerated. At this time, IRF services are 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fluid circulating cold pad with pump, any type 
(E0218) and a recliner chair (E1399, 99999). 
 
You asked the Plan to pre-approve a cold therapy machine and recliner. You say that you will be having 
shoulder replacement and is requesting a recliner chair and ice machine to help you recover after surgery. The 
Plan denied your request. The Plan says these items are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the fluid circulating cold pad with pump, any type (E0218) 
and a recliner chair (E1399, 99999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 3 Sensor continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider its denial. The 
Plan denied your request. The Plan says you do not meet criteria for a CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that a CGM 
is not medically necessary in this case. Our physician reviewer found you have diabetes and are currently using 
Ozempic since February 2023. You are currently using glimepiride since April 2023. You tried Jardiance from 
February 2023 through April 2023 and tried metformin in February 2023.The FreeStyle Libre 3 Sensor is not 
eligible for Medicare coverage under the durable medical equipment (DME) benefit because it is not classified, 
nor used with equipment classified, as DME. The review has determined that the requested FreeStyle Libre 3 
Sensor is not medically necessary or reasonable. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Freestyle Libre 3 Sensor continuous glucose monitor (CGM).
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 member meets full IRF criteria. The Plan denied 
your request. The Plan says the member does not meet Medicare IRF guidelines. 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service September 18, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the services billed. The 
Plan denied your request. The Plan says code 99223 is not supported by the medical record. The record doesn't 
support medical decision making of high complexity. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high 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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found high complexity is not evident as the focus of the review 
is the choice of antibiotic based on sensitivity. sensitivities are established. There are limited rather than 
extensive treatment options. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service September 18, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Zometa and Aredia. 
 
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 Xgeva. Our reviewer says that the 
request for Xgeva does not meet the Plan's criteria for step therapy. Our physician reviewer found the case file 
does not contain documentation of trial and failure of Zometa and Aredia. The documentation does not support 
that Zometa and Aredia would likely be less effective, and/or would likely have adverse effects for the enrollee 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 billed with code 81479 for date of service June 
6, 2022. You asked the Plan to pay for Guardant360. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test was not reported with an appropriate CPT 
code to correspond with the DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that for molecular diagnostic tests, such as the test at 
issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 have not been met. Specifically, we find that code 81479 is the most appropriate code 
for the test at issue. Although this test is covered by Medicare and the Z-code used is appropriate, the MolDX 
file for this test shows that certain CPT codes may be used to report this test, with code 0326U being the 
recommended code. Therefore, we decided that the Plan does not have to pay for Guardant360 billed with code 
81479 for date of service June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of a robotic surgical system in the performance 
of laparoscopic surgical closure of enterostomy with anastomosis. 
 
You asked the Plan to pre-approve the use of a robotic surgical system. You say that you say that the provider 
did not send the correct notes to support surgery. You also say that the provider now has the correct 
information. The Plan denied your request. The Plan says use of a robotic surgical system is not a covered 
service. 
 
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 use of a robotic surgical system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the types of instruments, techniques or approaches used are left to the discretion of the surgeon. As such, the requested code S2900 is not separately reimbursable.  
 
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 use of a robotic surgical system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the use of a robotic surgical system in the performance of 
laparoscopic surgical closure of enterostomy with anastomosis.