Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leg prosthetics (L5620, L5629, L5940, L5301) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve leg prosthetics. You say that the enrollee has been a long-term patient at a 
skilled nursing facility. The facility says that the in-network provider has made no attempt to see the enrollee. 
This is now delaying the enrollee's rehabilitation process. The enrollee would like you to continue providing 
service for him as he is comfortable with his providers and the service you have provided thus far. The Plan 
denied your request. The Plan says records received do not indicate that the enrollee has an emergent or urgent 
medical condition or are in need of specialized service(s) that are not available in the network. The enrollee has 
an HMO plan. There are in-network providers within a reasonable distance from his location that can provide 
this service or item. 
 
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 
leg prosthetics (L5620, L5629, L5940, L5301) to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you 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 you were admitted for gangrene, necrotizing fascitis of the foot and had a trans 
metatarsal amputation. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Medically necessary care 
can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 7, 
2021, through February 9, 2021, as billed with diagnosis code N17.9. 
 You asked the Plan to pay for the inpatient hospital services as billed. You say that the documentation supports 
the inpatient hospital care as originally billed. The Plan denied your request. The Plan says there is no support 
for the diagnosis code billed and subsequently the DRG billed is not supported. 
 
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 diagnosis code, N17.9, defined as acute kidney 
failure, unspecified. 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 as billed. Our reviewer says that the documentation does not support the inpatient hospital care as 
billed with the diagnosis code N17.9. Our physician reviewer found that the documentation indicates that the 
enrollee was a then, 67-year-old female who presented to the facility with complaints of right facial numbness 
and right hand numbness. The past medical history included hypertension, hyperlipidemia, diabetes mellitus 
type 2, chronic kidney disease stage 3, and tobacco use. The patient was admitted to rule out stroke versus 
transient ischemic attack. Neurology was consulted and magnetic resonance imaging of the brain noted an early 
subacute appearing lacunar infarct in the left thalamus. While documentation also noted a diagnosis of acute 
kidney injury, the clinical evidence did not support the diagnosis. 
 
In this case, while the initial creatinine was 2.3, the patient was noted to have chronic kidney disease stage III 
and no baseline creatinine level was provided. Nephrology was consulted and stated, "I suspect that the 
majority of her presentation is rather advanced stable chronic kidney disease stage III". On the day of 
discharge, the creatinine was 1.9 and documentation in the progress notes indicated "I suspect she is close to 
her baseline chronic kidney disease stage III." There was no evidence to support a creatinine level 1.5 times or 
more from baseline, and there was no indication of a decrease in urine output. The review has determined that 
the documentation did not support the billed diagnosis code N17.9 - acute kidney failure and the subsequent 
billed DRG.  
 
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 from February 7, 2021, through February 9, 2021, as billed with 
diagnosis code N17.9.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee on May 5, 2022. 
 
You asked the Plan to pay for the services. You say that you have a contract with the plan. The Plan denied 
your request. The Plan says that this was not billed 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. The provider has claimed that they have billed correctly based on their contract 
with the plan. The plan has not cited why this contract would not be valid in this case. The plan has not 
substantiated their denial. Therefore, we decided that the Plan has to pay for home health services provided to 
the enrollee on May 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. 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 an ILR. 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 history of a recent ambulatory ECG monitor having been performed to assess a possible 
arrhythmic etiology of syncope. There is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Durolane. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Monvosc, or Synvisc. The documentation does not support that Orthovisc, Monvosc, or 
Synvisc would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 64488-59 provided on May 16, 
2022. 
 You asked the Plan to pay for the injection services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says separate payment 
cannot be made for code 64488 as it is included in 00790. 
 
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 64488 is a column II code to column I code 00790; however, 64488 
was billed with a modifier.  
 
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 injection services as billed. Our reviewer says that the 
documentation does not support the services as they were billed for separate payment. Our reviewer found that 
the procedure report does not include enough documentation to confirm Transversus abdominis plane (TAP) 
block was not a part of anesthesia services provided. Medical record documents "Anesthesia Plan; ASA 3; 
general (TAP and rectus sheath block); The patient is not a current smoker.; intravenous induction; 
Postoperative administration of opiods is intended.; Trial extubation is planned.; Anesthetic plan and risk 
discussed with patient.; Use of blood products discussed with patient who.; Plan discussed with CRNA", and 
Peripheral Block; Patient location during procedure: OR; Start time: 5/16/2022 9:03 AM; End time: 5/16/2022 
9:14 AM Reason for block: at surgeon's request". In this case, the documentation should be clear to support the 
surgeon request for post-operative pain management. The documentation is insufficient to confirm modifier -59 
as billed. 
 
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 injection services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the injection services coded 64488-59 provided on May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that current evidence-based medical guideline and peer reviewed literature do 
not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition as discussed above. 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 device at L1-2 and 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total knee arthroplasty (27447) provided on January 18, 
2022. 
 
You asked the Plan to pay for the total knee arthroplasty (27447). You say that you were properly reimbursed 
for the services rendered and no refund will be issued. The Plan denied your request. The Plan says services of 
a Surgical Technologist are not separately reimbursable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the total knee arthroplasty (27447) 
provided on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on April 12, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that I havent 
had to pay a copayment for this service before. Why do I now? The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $125 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the Physician/Practitioner services, including doctors office visits benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan 
does not have to waive the copayment for a magnetic resonance imaging (MRI) provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 10, 2022, by an OON 
provider. 
 
You asked the Plan to pay for genetic testing. You say that you were referred to the provider who specializes in 
genetic testing. You say that at no time did anyone one consult with you as to who would do the test and it 
never occurred to you to ask the question. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 genetic testing provided on May 10, 2022, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coch implant microphone and a lithium ion battery 
provided on April 1, 2022, by an OON provider. 
  
You asked the Plan to pay for a coch implant microphone and a lithium ion battery. You say that you submitted 
a valid receipt for $505.00 for the purchase of the speech processor battery and microphone for the hearing 
aids. The Plan denied your request. The Plan says per your Plan's benefit for hearing aid services, you must 
obtain hearing aid equipment from the designated 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 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 a coch implant microphone and a lithium ion 
battery provided on April 1, 2022, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on February 5, 2022, and 
February 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services that were provided was 
medically necessary for you. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 the home health services provided on February 5, 
2022, and February 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillator. 
 
You asked the Plan to pre-approve a high frequency chest wall oscillator. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillator.