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 on December 29, 
2021, to December 31, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG 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 A41.9. 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 use of diagnosis code A41.9 is not supported by the records provided. Our physician 
reviewer found that the enrollee is a 76-year-old female who was treated in the hospital with pneumonia 
requiring antibiotics and fluids. The provided documentation describes the enrollee as stable in the emergency 
department prior to admission, on baseline oxygen (4-6L/m), normal platelets, normal bilirubin, GCS 15, 
normal kidney function, and without any other signs of organ dysfunction/failure related to a systemic infection 
process. The enrollee does not meet the Sepsis 3 criteria. The medical records, therefore, do not support the 
billing of A41.9 (sepsis).  
 
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 on December 29, 2021, to December 31, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Entyvio. Our reviewer says that the 
requirements for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial 
of Stelara before they will approve the requested drug, Entyvio. Based on the medical records provided there is 
no indication that the enrollee has tried and failed the Stelara. There is also no indication that Stelara would 
likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin graft substitutes. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that you 
have a diabetic or venous ulcer. The use of a skin graft substitute is not the standard of care for your condition. 
The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin graft substitutes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (K0553, K0554). 
 You asked the Plan to pre-approve the Dexcom continuous glucose monitor. You say that the Dexcom 
continuous glucose monitor is medically necessary and better than the plan options. The Plan denied your 
request. The Plan says this brand of glucose monitor is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The plan only covers Freestyle brand continuous glucose monitors. 
The records do not show a medical reason why the plan-preferred brand would be unsafe or ineffective for the 
enrollee. Based on this information, we decided that Medicare rules for coverage of the Dexcom continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and battery. 
 
You asked the Plan to pre-approve a power wheelchair and battery. 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee does not have a mobility deficit that impairs your participation in MRADLs. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair and battery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of irinotecan hydrochloride (HCL). 
 
You asked the Plan to pre-approve irinotecan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because irinotecan is 
not medically necessary. 
 
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 irinotecan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for irinotecan. Our physician reviewer found the requested use is 
not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This drug is not supported by 
one of the major drug compendia or by clinical research appearing in a Medicare-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 irinotecan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of irinotecan hydrochloride (HCL).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on January 7, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the 
documentation does not support payment for the hospital discharge day management services as 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 code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
indicate that more than 30 minutes were spent on the hospital discharge day management services. Based on 
this information, we decided that Medicare rules for coverage of the hospital discharge day management 
services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge 
day management services (99239) provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot receive appropriate 
level of nursing care in lower level of care. You say that the enrollee meets medical complexity requiring 
physician oversight as well as skilled therapy. The Plan denied your request. The Plan says LTACH services 
are not medically necessary, and services could be provided in another setting, such as an acute rehabilitation 
facility, skilled nursing facility, outpatient setting or home care. 
 
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 records indicate that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The medical records do not indicate that the enrollee 
requires services that she 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic companion pet under the Special Supplemental 
Benefits for Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve a robotic pet. You say that you feel it is ridiculous that you have to have a 
form filled out for a robotic pet. You also say that your provider stated they did not receive a form. The Plan 
denied your request. The Plan says the attestation form was not returned in order to verify that you meet all of 
the SSBCI requirements. The Plan also says that the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a robotic pet have not been met. Specifically, an attestation form to support that you meet the 
requirements of the SSBCI benefit has not been received by the Plan. Therefore, we decided that the Plan does 
not have to pre-approve a robotic companion pet under the Special Supplemental Benefits for Chronically Ill 
(SSBCI) benefit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on May 19, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested drugs (J3490) is included in the global 
surgery payment for the procedure (62321) provided on the same date. Separate payment cannot be made for 
the requested drugs. Based on this information, we decided that Medicare rules for coverage of the drugs have 
not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J3490) provided on May 
19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
6, 2021, to December 31, 2021. 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 6, 2021, to December 31, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177) 
and CT of the chest (71260). 
 
You asked the Plan to pre-approve the CT scans. The Plan denied your request. The Plan says that this request 
cannot be approved. 
 
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 the CT scans. Our reviewer says that 
the CT scans are reasonable and necessary. Our physician reviewer found the enrollee has been discovered to 
have antibodies which place them at marked elevation of risk for occult malignancy. Our reviewer also found 
that the request for a screening CT of the chest, abdomen and pelvis is thus reasonable 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 CT scans have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) of the abdomen and pelvis (74177) and CT of the chest (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on December 19, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that this equipment was medically 
necessary for your condition. The Plan denied your request. The Plan says prior authorization was not obtained 
for these services provided by an OON 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 durable medical equipment provided on December 
19, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous neurostimulator implantation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous neurostimulator implantation is 
covered when 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She has had injections, acupuncture, chiropractic therapy, and massage therapy. There is no documentation of a 
recent surgical consult or trials of various combinations of intra-thecal medications. The services are therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous neurostimulator implantation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process 
stabilization device (22869). 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that the requested service would provide 
significant clinical and quality of life benefits for the enrollee. You also say that this treatment is medically 
necessary and appropriate for this stage of the disease progression. The Plan denied your request. The Plan says 
the requested service 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 Vertiflex Superion device. Our 
reviewer says that the requested Vertiflex Superion device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found 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. The 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 device 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of interlaminar/interspinous process stabilization device 
(22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 17, 2021, to April 
19, 2021, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not appropriate as the diagnosis of S42.002K (Fracture of unspecified part of left clavicle, subsequent encounter for 
fracture with non-union) is not supported in the medical record. 
 
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. 
 
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 inpatient care billed with DRG 872. Our 
reviewer says that the diagnosis of S42.002K (Fracture of unspecified part of left clavicle, subsequent 
encounter for fracture with non-union) is not supported in the medical record for this inpatient admission. Our 
physician reviewer found that the enrollee was treated in the hospital with intracranial hematoma after a 
mechanical fall. Computed tomography (CT) showed a chronic deformity of the distal clavicle. Documentation 
does not, however, describe a non-union fracture of the clavicle related to this hospital stay that was actively 
treated. The medical records, therefore, do not support the billing of S42.002K (Fracture of unspecified part of 
left clavicle, subsequent encounter for fracture with non-union). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 17, 2021, to April 19, 2021, 
as billed with Diagnosis Related Group (DRG) 872.