Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 77066 and G0279 for services provided on July 2, 
2021. 
 
You asked the Plan to pay for codes 77066 and G0279. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 3, 2021 and August 10, 2021. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for codes 77066 and G0279 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 77066 and G0279 for 
services provided on July 2, 2021.
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 has had a very long and 
complicated hospitalization and it is your strong recommendation that he be approved for admission to the 
LTACH level of care. The Plan denied your request. The Plan says the request is not medically necessary, 
when the enrollee is ready to leave the hospital, they can safely receive this care in another setting, such as a 
Skilled Nursing Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
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 pre-approve the outpatient facility services provided from June 28, 
2021, through July 9, 2021. 
 You asked the Plan to pre-approve the outpatient facility services. You say that the claim should be paid. The 
Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient facility services have 
been met. The Plan requested medical records that showed the enrollee was receiving inpatient care and was 
discharged before they started to receive home health care. Nothing was sent back to demonstrate that inpatient 
care was received. Therefore, we decided that the Plan does not have to pre-approve the outpatient facility 
services provided from June 28, 2021, through July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. 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, 
Infed and Venofer. 
 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 Feraheme. Our reviewer says that the 
step therapy criteria have been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication 
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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick system. 
 
You asked the Plan to pre-approve a Purewick system. You say that the requested Purewick is medically 
necessary. The Plan denied your request. The Plan says the requested Purewick 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 a Purewick system. Our reviewer says 
that the requested Purewick system is not medically necessary. Our physician reviewer found there are no peer-
reviewed articles published in the medical literature specific to the PureWick system, or external urinary 
collection system using a continuous low-pressure pump. Thus, there is no evidence to show the PureWick system to be an effective alternative in managing urinary incontinence. 
 
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 Purewick system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Purewick system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 12, 2022, to 
May 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 12, 2022, to May 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use of Keytruda is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requirements for coverage of Keytruda have not been met. Our physician reviewer found the requested use of 
Keytruda in combination with paclitaxel and carboplatin is not Food and Drug Administration-approved for the 
enrollee's diagnosis of malignant neoplasm of unspecified part of right bronchus or lung who has had disease 
progression with prior pembrolizumab treatment. It is also that not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of a neurostimulator 
electrode array and an implantable nuerostimulator electrode. 
 
You asked the Plan to pre-approve the percutaneous implantation of a neurostimulator electrode array and an 
implantable nuerostimulator electrode. You say that the requested services are needed in order to help with his 
constant pain. The Plan denied your request. The Plan says the clinical information provided does not show that 
the requested services are medically necessary.  
The Plan follows Medicare rules. Medicare rules say that the implantation of dorsal column or depth brain 
stimulators are only covered for certain indications.  
 
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 percutaneous implantation of a 
neurostimulator electrode array and an implantable nuerostimulator electrode. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no documentation of a clear 
indication for a spinal cord stimulator. There is no psychological clearance. There is no documentation of the 
conservative therapies that have been trialed and failed. The requested services are not considered medically 
reasonable and 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 percutaneous implantation of a neurostimulator electrode array and an 
implantable nuerostimulator electrode have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the percutaneous implantation of a neurostimulator electrode array and an implantable 
nuerostimulator electrode.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the chest with contrast (71260). 
 
You asked the Plan to pre-approve a CT of the chest. You say that an MRI was done but did not provide what 
the doctor is looking for, which is to evaluate for any small bowel inflammatory process that may be going on. 
You also say that the CT was not only requested for weight loss. The Plan denied your request. The Plan says 
that the CT scan of the chest is not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT of the chest. Our reviewer says 
that the enrollee meets the criteria for coverage for a CT of the chest. Our physician reviewer found the enrollee 
weighs 230 pounds and has lost 20 pounds unintentionally over the past year. Our reviewer found that 
according to the guidelines, unintentional weight loss of equal or greater than 10 pounds or greater or equal to 
5% of total body weight over the past 6 months qualifies a patient for a CT of the chest to look for occult 
malignancy or other related findings. Our physician reviewer also found that according to these guidelines the 
enrollee thus qualifies for the requested CT of the chest. 
 
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 CT of the chest have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) of the chest with contrast (71260).  
 
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 pay for inpatient hospital services provided on July 6, 2021, to July 
9, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that sepsis was 
consistently documented. The Plan denied your request. The Plan says the diagnosis is not valid. 
 
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 with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the hospital with a skin infection 
and possible abscess. The initial labs noted a white blood cell count of 15.2. The enrollee was admitted as an 
inpatient to be treated for cellulitis. For completeness, severe sepsis is defined as sepsis complicated by organ 
dysfunction. In this case, there was no clinical or laboratory evidence of sepsis. The review has determined that 
the records did not support the billed diagnosis. 
 
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 July 6, 2021, to July 9, 2021, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 21, 2022 to 
February 25, 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 you 
stand by the use of this diagnosis code and DRG. The Plan denied your request. The Plan says the Plan has 
removed the secondary diagnosis code of J96.01. 
 
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 J96.01. 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 requested DRG code does not meet criteria for payment. Our physician reviewer found the record 
includes insufficient and inconsistent documentation to confirm acute respiratory failure. The record describes 
an emergency department visit documenting shortness of breath, chest heaviness, and oxygen saturation 82%. 
The enrollee was placed on 2 to 3 liters of oxygen via nasal cannula. No respiratory distress was documented, 
and no blood gases were noted in the record. Although acute respiratory failure is documented, there is 
insufficient documentation to support care and treatment for acute respiratory failure diagnosis.  
 
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 February 21, 2022 to February 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex superion interspinous 
spacer at L4-5, in this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2022, to 
March 23, 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 
provider submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says the determination to remove principal diagnosis code assignment of A41.89 (Other 
specified sepsis) is upheld. 
 
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 A41.89 - Other specified sepsis. 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 physician reviewer found the enrollee did not have sufficient evidence of sepsis based on the Sepsis 3 
criteria. Therefore, the diagnosis of sepsis is not supported by the documentation for this admission.   
 
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 March 15, 2022, to March 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services billed with code 78315 provided on April 
23, 2022. 
 
You asked the Plan to pay for code 78315. The Plan denied your request. The Plan says this claim is a duplicate 
of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 2, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for code 78315 have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services billed with code 78315 provided on April 23, 
2022.