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

 
We decided that the Plan does not have to pay for the inpatient hospital services provided to the enrollee from 
March 15, 2021 to April 2, 2021. 
 
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 DRG was updated.  
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 DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 review has determined that the records did not support the use 
of diagnosis code A41.02 - sepsis due to methicillin resistant staphylococcus aureus - in this case. The records 
do not support the use of DRG 872 in this case. While it is acknowledged that the records include a physician-
documented diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were 
present along with an elevated lactic acid, the clinical findings in the record do not sufficiently support the 
diagnosis of sepsis based on Sepsis 3 criteria.  
 
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 the inpatient hospital services provided to the enrollee from March 15, 2021 to April 2, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left knee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there has not been completion of six weeks of provider-directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the physical exam of 
the left knee revealed diffuse tenderness, and importantly a joint effusion. The presence of a documented joint 
effusion amounts to a red flag, and as such the MRI of the left knee should be authorized, even absent a six 
week trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the left knee.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2002). 
 
You asked the Plan to pre-approve non-emergency transportation. You say that you would like transportation 
as part of your service back. You also say that it is very hard to make doctor appointments without this benefit. 
The Plan denied your request. The Plan says routine transportation is not a covered service under regular 
Medicare and therefore is not covered by the plan.  
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transportation have not been met. Specifically, the file 
does not indicate that the plan offers a supplemental benefit for routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency transportation (T2002).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated resin crowns (D2932) for teeth # 12, 13, 
14 and 15. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says prefabricated resin crown is not listed as a covered dental service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested prefabricated resin 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve prefabricated resin crowns (D2932) for teeth # 12, 13, 14 and 15.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have any transportation to 
your dialysis appointments three times per week. The Plan denied your request. The Plan says you have 
exhausted the established benefit of 24 trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to twenty-four (24) (one way) trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and does not require transfer to an LTACH. 
 
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 the enrollee appears to be improving but is still somewhat unstable (high flow 
oxygen requirement) and should only require short-term additional acute care services that can safely be 
administered at the current facility until more stable and appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available and covered at the current facility. There are 
no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
you and/or your provider are requesting do not meet the requirements for approval. 
 
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 the enrollee appears to be improving and is stable and should only require short-
term additional acute care services that can safely be administered at the current facility until appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available and 
covered at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would 
not be clinically advantageous. Completion of treatment at the current facility is recommended 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 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 infusion services (procedure code J7050) provided to the 
enrollee on September 9, 2021. 
 
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 fluid used to administer the drug(s) is incidental hydration and is not separately payable. 
 
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 J7050 is "Infusion, normal saline solution, 250 cc." 
 
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 procedure report does not 
include documentation to support that normal saline was provided for other than used to administer the drug; 
therefore, this procedure would be included in the drug infusion procedure code. 
 
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 infusion services (procedure code J7050) provided to the enrollee on September 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on January 4, 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 the criteria was not met for CPT 99285. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our physician 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 review has determined that 
the criteria was not met for CPT 99285. There was no documentation of medical decision making of high 
complexity. 
 
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 emergency department services (procedure code 99285) provided to the enrollee on January 4, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) imaging of the 
brain for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, as it does not meet Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found that the enrollee is 
noted to have memory problems. They are primarily suspected of having Alzheimers disease versus changes 
due to a mood disorder. The enrollee however is not noted to meet diagnostic criteria for both AD and FTD.  In 
as much this would not meet the requirements of the NCD for coverage of this service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) imaging of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 16, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on March 16, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second chest x-ray provided to the enrollee on February 28, 
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 coding guidelines have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 provider says that a second exam was done on the same date. However, the records only show one single view chest exam done on 
2/28/22. 
 
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 a second chest x-ray provided to the enrollee on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the compression stockings to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the compression stockings. You say that the OON provider is the only 
provider who has the plain white stocking you need. The Plan denied your request. The Plan says the requested 
provider is an OON provider and there are in-network providers available to provide the service requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the compression stockings to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option. 
 
You asked the Plan to pre-approve group 3 power wheelchair with single power option. You say that the power 
tilt is needed to meet the enrollee's medical, functional, and mobility needs. The Plan denied your request. The 
Plan says the denial of authorization for this device is correct, because the enrollee does not need the power tilt 
option and the enrollee's condition is instead appropriate for a group 3 power wheelchair with no power 
options. 
 
The Plan follows Medicare rules. Medicare rules state that a group 3 power wheelchair with single power 
option is only covered if specific criteria are met. 
 
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 group 3 power wheelchair with single 
power option. Our reviewer says that the enrollee does not meet criteria for a group 3 power wheelchair with 
single power option. Our physician reviewer found the enrollee is also able to use a quad cane for short 
distances that are non-functional and is able to transfer, thus would not require a group 3 power wheelchair 
with power tilt because the enrollee is able to functionally pressure relief.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with single 
power option.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you were referred to the out-of-network provider. 
The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.