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 need a higher level of care that a skilled nursing 
facility can't provide. You say you want to regain maximum strength and functions so you can be independent. 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (E0770). 
 
You asked the Plan to pre-approve the functional electrical stimulator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for the use of functional electrical 
stimulation is limited to spinal cord injury patients for walking, who have completed a training program which 
consists of at least 32 physical therapy sessions with the device over a period of three months. 
 
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 functional electrical stimulator. Our 
reviewer says that this device is not medically necessary. Our physician reviewer found the records do not 
show that the patient has a spinal cord injury or otherwise meets coverage criteria. 
 
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 functional electrical stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a functional electrical stimulator (E0770).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs related to his comorbidities. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an IRF stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for syncope and bradycardia. The enrollees medical problems are stable, and there 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee may have 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 an IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the extracapsular cataract removal with insertion of intraocular lens 
prosthesis (66984) provided November 22, 2021. 
 
You asked the Plan to pay for the cataract surgery. You say that please review and process this surgery so that 
you can close this date of service. The Plan denied your request. The Plan says that additional records are 
required to support medical necessity for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cataract surgery. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found visually significant cataract in the left eye per clinical notes. The cataract extraction/removal 
coded as 66984 was appropriate and 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 cataract surgery have been met. Therefore, we decided that the Plan has to 
pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) provided 
November 22, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these lab services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37220, 37222 and 75625 provided to the 
enrollee on January 27, 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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
 
 CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
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 documentation does not 
support coverage of the procedures in question. In terms of CPT 75625, this codes for the supervision and 
interpretation of an angiogram of the aorta.  There is insufficient detail with respect to the aortogram findings 
to reach a minimal threshold of documentation to be able to overturn the health plan determination. Similarly, 
codes 37220 and code 37222 respectively cover for initial and additional iliac artery angioplasty. There is 
insufficient documentation of that portion of the procedure that demonstrates that meaningful angioplasty was 
performed and what the results were. Additionally, it is not possible to determine if both the common and 
external iliac arteries were treated with the same balloon which be a different coding situation than if they were 
separately treated. 
 
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 procedure codes 37220, 37222 and 75625 provided to the enrollee on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 10, 2022, to 
January 17, 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 these 
services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says the DRG submitted on this claim is not supported in the medical records. 
 
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 sepsis, unspecified organism (A41.9) and severe 
sepsis without septic shock (R65.20). 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 these diagnoses are not 
supported in the medical records provided. Our physician reviewer found that the enrollee presented with 
failure to thrive, not taking medications and not eating well for the prior few days. He was found to have 
cellulitis of an extremity wound and was treated with antibiotics, wound care, and fluids. He presented with 
some shortness of breath that was discovered as related to COVID-19 and chronic obstructive pulmonary 
disease (COPD). Creatinine was 2.7 (baseline 2.4), Glasgow Coma Score (GCS) was 15, platelets were 306, 
bilirubin was 0.4, blood cultures were negative, and blood pressure wasn't significantly low following initial 
treatment. Based on the objective workup, the enrollee did not have sufficient evidence of a dysregulated 
immune response to the cellulitis infection and so the Sepsis 3 criteria was not met. Therefore, the diagnoses 
of sepsis, unspecified organism (A41.9) and severe sepsis without septic shock (R65.20) were not supported by 
the provided documentation.   
 
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 January 10, 2022, to January 17, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgery. 
 
You asked the Plan to pre-approve vascular surgery. 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 vascular surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no description of the enrollees symptoms other than he is doing well. The 
evaluation does not include a pulse examination or an ankle brachial index (ABI).  There is a recent angiogram 
describing patent right lower extremity arteries including two-vessel runoff. There is an isolated, single tibial 
artery occlusion. As the documentation does not provide an indication or rationale for the treatment in question, 
and the diagnostic angiogram suggests satisfactory perfusion to the right lower extremity, the requested 
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 vascular surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve vascular surgery.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99202) and 3D rendering (76376) provided on October 
20, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this provider is listed on the Plan's website 
as in-network. You say that when you called to make an appointment you were advised that the provider did 
not accept Medicare. You say that you contacted the Plan due to the conflicting information. You also say that 
the Plan representative advised the provider was in-network. The Plan denied your request. The Plan says that 
the claim denied correctly. 
 
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. Specifically, the Plan has not supported their denial. The documentation 
provided indicates that the enrollee was informed by a plan representative that this provider was in-network. 
The Plan did not address this. Additionally, the record shows that the provider in this case is listed on the Plan's 
website as an in-network dental provider. Therefore, we decided that the Plan has to pay for the office visit 
(99202) and 3D rendering (76376) provided on October 20, 2022.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF admission is not supported based on 
the records received. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that this services is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
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 the intracept procedure (64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on 
October 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
(A4595), provided on October 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says the documentation does not support the coding criteria. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
at minimum 15 different drug classes were tested. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code G0482 billed for date of service September 14, 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 the enrollee would benefit from continued 
occupational and physical therapy services to maximize independence. The Plan denied your request. The Plan 
says the records do not show that the enrollee will be able to tolerate the intensity of 3 hours of daily therapies 
in the IRF setting. 
 
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, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program. 
 
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.